We all know there are manufacturers and distributors.  A manufacturer typically builds equipment or devices, takes them through Federal Drug Administration testing and then applies for a Current Procedural Terminology (CPT) or a Healthcare Common Procedural Coding System (HCPCS) code to be approved for the device/equipment.

Sales representatives market to hospitals, physicians, durable medical equipment providers, and others the device or equipment.  The device or equipment can be used in a procedure or sold as a product and the provider can make specified dollars using the code the sales representative tells them to use.

As providers, we need to be proactive in making sure anything billed Is accurate up to and including the coding for devices and procedural codes.  Billing a device under the wrong procedure code in a recoupment and could include monetary penalties.  The payers start with the providers first and any dispute the provider has is their responsibility to seek action against the manufacturer or distributor.

I am sure manufacturers, nor their sales representatives intend to misguide you.  As information is disseminated, pieces get lost in translation or misunderstanding of terminology.  It is the providers responsibility to ask for proof.  Misinformation can happen in all industries mentioned above from the wrong HCPCS code for wound care tape to wrong CPT for an implanted electronic stimulation device.

The proof you should as for includes but may not be limited to the following:

• Any written communication from Pricing, Data analysis, Coding Contractor (PDAC) for HCPCS Code assignment or American medical Association (AMA) for Procedural CPT Code assignment and who can perform the treatment or procedure with the device/equipment.
  • HCPCS typically equipment that is used or applied by the patient such as Transcutaneous Electronic Nerve Stimulation (TENS), Sleep Apnea equipment, braces, wheelchairs, etc. Can be used by a patient without clinical supervision.
  • CPT is performed typically in a clinical setting and sometimes invasive. Procedures such as implanted electronic stimulation (invasive), oral appliance for sleep apneas must be fitted by a dentist, and others.
• Any marketing material from the manufacturer instruction a code associated with the device or equipment.
• Any direction from the manufacturer or distributor about the clinical plan of care associated with the device.
• Any direction regarding payers and the device/equipment in question.
• If they are unwilling or unable to provide this documentation, abort the mission! Do not pay for research that should be given to you if they want to make a sale.  No verbal information alone is acceptable.

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Prepared by: Angela Miller, CMC, CHC with Medical Auditing Solutions, LLC