A manufacturer of urological products faced an important hurdle as it prepared to bring a new urine management product line to market. Before its products, which were designed to assist bedridden patients, could be billed to Medicare, they needed to be assigned the appropriate Healthcare Common Procedure Coding System (HCPCS) codes.
Securing formal code verification from the Pricing, Data Analysis and Coding (PDAC) contractor would require extensive supporting documentation demonstrating that the products met the requirements of the requested codes. Because the manufacturer was seeking assignment to newly created codes within the durable medical equipment (DME) benefit category, the submission was likely to receive particular scrutiny.
The manufacturer turned to Applied Policy to build its case. We worked with the company’s research and development and quality assurance teams to identify and assemble the product testing, technical specifications, and other evidence needed to demonstrate that the products met Medicare’s DME requirements, including its three-year durability standard. We then translated that technical evidence into a clear rationale for assignment to the requested codes and ensured that the submission was complete before it went to PDAC.
PDAC assigned the products to the requested HCPCS codes.
That determination cleared an important obstacle to commercialization. With code verification secured, the manufacturer could move forward with its product launch with an established coding pathway for Medicare claims, allowing it to begin pursuing reimbursable sales as soon as the products entered the market.
For manufacturers developing new medical technologies, even an innovative, market-ready product can face delays if its Medicare coding pathway is uncertain. In this case, Applied Policy brought together the client’s technical expertise and our knowledge of Medicare coding and DME requirements to secure the coding determination the manufacturer needed to move its products into the market.
