by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Nov 24th, 2014 - Reviewed/Updated Aug 9th
The PDAC (Medicares - Pricing, Data Analysis and Coding) receives frequent inquiries regarding a billable HCPCS code and a payable HCPCS code. One may think the two are the same; however, this is not the case.
A billable HCPCS code is one that is submitted on a claim to the DME MAC. A billable HCPCS code will display as active on DMECS (no end date). If the HCPCS code is billable to the DME MAC it does not necessarily mean it is payable.
A payable HCPCS code is one that will be considered for payment by the DME MACs if the item meets the definition of DME, falls under a benefit category, and is covered under other general DME guidelines. Specific details can be found on the applicable DME MAC web site for which you are billing.
When inquiring about a HCPCS code to determine if the code is billable or payable to a DME MAC, first check the National Coverage Determination (NCD), the Local Coverage Determination (LCD), and the DME MAC web site to determine whether the code is billable and/or payable.
Example: HCPCS code A5510 is currently listed on DMECS as a billable code to the DME MAC. The current LCD states: “Items represented by code A5510 reflect compression molding to the patient's foot over time through the heat and pressure generated by wearing a shoe with the insert present. Since these inserts are not considered total contact at the time of dispensing, they do not meet the requirements of the benefit category and will be denied as non-covered”. The LCD indicates that this HCPCS code is billable but not payable by the DME MACs.
References/Resources
About Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Christine Woolstenhulme, CPC, QCC, CMCS, CMRS, is a Certified coder and Medical Biller currently employed with Find-A-Code. Bringing over 30 years of insight, business knowledge, and innovation to the healthcare industry. Establishing a successful Medical Billing Company from 1994 to 2015, during this time, Christine has had the opportunity to learn all aspects of revenue cycle management while working with independent practitioners and in clinic settings. Christine was a VAR for AltaPoint EHR software sales, along with management positions and medical practice consulting. Understanding the complete patient engagement cycle and developing efficient processes to coordinate teams ensuring best practice standards in healthcare. Working with payers on coding and interpreting ACA policies according to state benchmarks and insurance filings and implementing company procedures and policies to coordinate teams and payer benefits.
Quick, Current, Complete - www.findacode.com