Palmetto GBA is best known as a Medicare claims processor, but its broad capabilities include medical review, website and portal development and network and systems solutions. A lesser known, but vital group is the Pricing, Data Analysis and Coding (PDAC) lab. PDAC is contracted by the Centers for Medicare & Medicaid Services (CMS) to ensure medical equipment and supplies meet Medicare standards. It also protects the Medicare Trust Fund through diligent data analysis and reporting. Through their work, PDAC helps CMS set market-based payment rates for certain medical products, which limits Medicare fraud and abuse and saves money for Medicare beneficiaries and taxpayers.

Product Review and Code Verification

One of PDAC’s primary responsibilities is performing code verification reviews for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS). With the exception of supplies, these products are designed for long-term medical use in the home by patients for daily living. Manufacturers or distributors submit these items to PDAC to ensure they comply with CMS billing code standards—the Level II Healthcare Common Procedure Coding System (HCPCS). This process often involves product testing by a biomedical engineer in a lab at the Columbia location.

The review team of licensed medical professionals, including physicians, registered nurses and an orthotist/prosthetist, evaluates the products. They verify that the products submitted for review meet Medicare coding policy, are approved for marketing in the U.S. by the Food and Drug Administration and that the features and functions of the devices are the same or similar to the original product for which the HCPCS code being assigned was created. The products they review range from surgical dressings to complex devices such as artificial limbs or battery powered mobility wheelchairs.

Test Ride: PDAC team members (from left) Sampat Nidadavolu, Dr. Jason Stroud, Ryan Lewis and Anna Wingard Cocke prepare to take battery powered mobility wheelchairs for a test ride during a recent wheelchair demonstration attended by several manufacturers.

Essential Systems and Expert Support

Along with maintaining several drug pricing files on their website, PDAC also manages the DME Coding System, which includes the Product Classification List. This system, which also includes HCPCS details and code history, is a vital resource for suppliers and manufacturers, providing up-to-date information on coding and DMEPOS fees.

To assist suppliers and manufacturers, PDAC operates a dedicated call center. The HCPCS Helpline answers questions about the code verification review process and provides HCPCS coding guidance for Medicare billing, ensuring stakeholders have the support they need to navigate the complex coding system. They also provide routine support to several government contracts and agencies, including the Durable Medical Equipment Medicare Administrative Contractors (DME MACs), CMS, unified program integrity contractors, federal law enforcement agencies and various other benefit integrity contractors.

Protecting the Medicare Trust Fund

PDAC’s data analysis and reporting activities are essential in protecting the Medicare Trust Fund. They identify overuse and potential fraud and abuse, which helps drive policy development related to DMEPOS. Their work also focuses on medical review activities and monitoring the enrollment and billing activity of DMEPOS suppliers, which contributes to the integrity and efficiency of the Medicare system.