DMEPDAC List

DMEPDAC List

Wil

1/1/2013

Hello Colleagues and Guests,

I, and a few other ole timers in the field are concerned about the
apparent lack of transparency regarding the DMEPDAC listing, which seems
to be getting more important to the O&P field as the years go by. During
the past few years, I have noticed many changes in wording regarding the
definitions for various LCodes. At times, I wonder whether the
categorization system that Dr. Perry was largely responsible for is even
understood. I also realize this it is not a perfect system and that
change does, perhaps, need to occur to some extent. So, as a refresher,
when I was taught the language of O&P, it boiled down to a relatively
simple system that went like this. If the device crosses the joint line
and can create a responsible force system of the joint involved, that
section of anatomy was included. Hence, the term AFO simply means that
the system can effect a responsible force vector at the ankle. Because
the foot is one of the AFO termination points and can also be involved
in motion control, it too is included and orthosis is the noun used to
describe brace. As such, if a client's tissue can appropriately
tolerate the forces involved with the force vectors involved, the height
above the ankle is really not particularly relevant for an AFO. This, I
believe, was largely the intent of the categorization of O&P terms that
we currently use. When it came to spinal devices, the intent of control
was based upon a region, such a lumbar, thoracic, etc, but the virtual
joint line was included for each device. Of course, there are most
always exceptions to rules and, for example, the Dennis Brown Splint may
be one of those devices. If, the device crossed the joint line and had a
purpose for crossing that joint, that section of anatomy was included.
Now, if the academic gurus out there would straighten me out about this
if I'm wrong, I would appreciate hearing from you.

Words that have disappeared in recent years primarily relate to terms
like thermoplastic or equal to, etc. Terms for spinal devices have
recently included Sacrococcygeal junction to T-9 vertebra, etc. So, in
essence the terms for devices have changed that, in some cases, have
opened Pandora's box regarding materials, etc., and in a practical
manner of speaking, the spinal definitions do not seem practical either.
In fact, if I was an auditor and used the current spinal definitions,
the denial rate would likely be nearly 100%. Frankly, who give a rats
you-know-what if the termination point for a spinal device hits the
sacrococcygeal junction, as long as the intended treatment results are
obtained?

If you are still awake thus far, you may want to continue reading. You
can go to the /OP-Repository.org web site/ and take a look at the
DMEPDAC file that I've posted. You may need a program (such as Excel)
that will read a .cvs file, but that should be all that is necessary.
/The file is located under Documents, then NAS./

Here is the issue. I started with over 85000, records in this DMEPDAC
file. This included baby formula and a host of other non-O&P related
items. I have since pared it down to items that I believe need to be
looked at regarding our future ability to maintain control of the O&P
LCode system. Last week, I called the DMEPDAC folks and asked who was
responsible for determining how a code gets assigned and was told this
is done by Medicare or CMS. I asked who specifically within the CMS
system I could contact to find out more and was not given much help. I
also asked if the list was up to date and was told that it was. I
explained that there were items that could not be found from their list
at a manufacturers website or in their catalogs. Then I was told that it
was the manufacturer's (or supplier) responsibility to notify the
DMEPDAC system when an item is no longer valid. I was also told that
each submission for inclusion on the lists must contain marketing
information regarding the item and its associated catalog or part
number. But there is no transparency to support such claims. I guess I
need a DMEPDAC 101 course and would appreciate a tutor on this subject.

Here is the problem. O&P Lcodes were developed by orthotists and
prosthetists in consultation with Medicare and this no longer seems to
be the case. It appears that devices are submitted and approved for use
within the LCode system in a black box and there is no transparency
regarding this issue. Furthermore, it appears that the DMEPDAC list is
not up to date and is erroneous in many other ways as well. Tell me,
what good is a list that is not accurate? Isn't it about time we hold
CMS accountable for their mistakes, since they seem intent on pointing
all of our mistakes out to the public? I noticed recently that some of
what I believe are LCode devices have now been relegated to the ECode
(DME) department. Frankly, this is very concerning to me and it should
be to you as well. If orthotists and prosthetists are no longer needed
and looked upon as a complement to the orthopedic world, then LCodes do
not need to exist. Furthermore, if you can purchase an LCode device at
Walmart or online without a prescription, then should not these devices
simply be stricken from the CMS system? Why would we pay someone in the
government to control a list that is essentially meaningless? I
understand that Blue Cross and some of the other insurers may look at
codes differently than Medicare, but my experience tells me that this
fact is quickly disappearing.

I have included many more items (24,000) than would likely end up on the
professional orthotist and prosthetist LCode listing. These include A,
K, E and perhaps one or two more categories, in addition to the LCodes.
The purpose for this is so you can get an idea of what the trends are
regarding O&P care and the devices approved for same by CMS. This list
was downloaded from the DMEPDAC system today, so it is the latest
version available. If we do not take the time to examine and challenge
codes, when necessary, that are issued by CMS regarding O&P, we have no
basis for complaint as the O&P LCode system slips through our fingers.
This discussion really needs to be on an active O&P blog so that we can
collectively get to the bottom of this important topic. Shoes, for
example, boggle my mind inasmuch that I am somewhat familiar with the
specifications required by CMS to meet the diabetic shoe bill
requirements. There are nearly 5,000 shoes for A5500 approved, (it
appears with many more pending?) but in some cases, little is said about
meeting the diabetic therapeutic shoes regulations. Once again, if shoes
are not unique in the manner that they protect diabetic feet, as
required by CMS regulations, should they exist on the CMS system?
Regarding the accuracy of the DMEPDAC list, I had to go 1300 records
down, sorted by ACodes (and the sort was not totally accurate in itself
indicating there might be a corrupted field problem) in order to find
the first item that appears on the 2013 CMS /fee schedule /and that
happened to be an Innovative Neurotronics code (A4595). Are the codes
preceding this code obsolete or are they sitting in limbo awaiting
inclusion into the system? And the questions just keep going. I have not
even touched upon the prosthetic world, but that too appears to need
evaluating, although it is likely a little more straight forward.

In my opinion, this issue funnels directly into our larger issues
regarding audits, definitions of comprehensive services, medical
necessity, and so forth. Holding citizens accountable for their actions,
as CMS is now doing to O&P in a lawn-mower-like manner, requires that
citizens hold CMS and other government agencies and officials
accountable for their actions as well. I wish we understood that better.
If it turns out that we are all a bunch of crooks, well........, then I
guess the story will end.

As always, your comments are appreciated.

Wil Haines, CPO
MaxCare Bionics
Avon, IN 46123



                          ********************
To unsubscribe, send a message to: <Email Address Redacted> with
the words UNSUB OANDP-L in the body of the
message.

If you have a problem unsubscribing,or have other
questions, send e-mail to the moderator
Paul E. Prusakowski,CPO at <Email Address Redacted>

OANDP-L is a forum for the discussion of topics
related to Orthotics and Prosthetics.

Public commercial postings are forbidden. Responses to inquiries
should not be sent to the entire oandp-l list. Professional credentials
or affiliations should be used in all communications.