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Rehabilitation engineering in the assistive technology industry
Published in Alex Mihailidis, Roger Smith, Rehabilitation Engineering, 2023
The United States government maintains a formal coding system for a subset of AT called durable medical equipment (DME). The DME designation is restricted to devices and services that are medically necessary. The US Centers for Medicare and Medicaid (CMS) maintain the Healthcare Common Procedure Coding System (HCPCS), a formal coding system for devices and services deemed medically necessary. The HCPCS Level I is comprised of numeric codes and descriptive terms of medical services and procedures performed by physicians and other healthcare professions. Level II provides codes to identify product, supply and service categories that are not covered under Level I, such as durable medical equipment, prosthetics, orthotics and supplies (DMEPOS). The HCPCS codes standardize information to help plan, implement and evaluate procedures, for billing and collections, and to conduct comparative efficacy studies. Given that the HCPCS codes drive the payment/reimbursement systems, companies within the AT industry are eager to comply with all reporting requirements, thereby keeping the content comprehensive and accurate. Unfortunately, the criteria requiring medical necessity justification preclude the HCPCS system from coding and covering the wide range of AT products and services that are non-medical (e.g., vision, hearing, speech and haptic interfaces for information and communication technologies; environmental modifications).
Bringing Regenerative Medicine to Patients: The Coverage, Coding, and Reimbursement Processes
Published in Karen J.L. Burg, Didier Dréau, Timothy Burg, Engineering 3D Tissue Test Systems, 2017
Khin-Kyemon Aung, Scott Levy, Sujata K. Bhatia
A new HCPCS code, even if temporary, can also help a new device manufacturer, particularly if a new CPT code is delayed, denied, or not sought. A new HCPCS code enables providers and payers to specifically reference a company's device in bills, enabling CMS and others to collect data on the device's clinical efficacy and costs. Manufacturers often use these data in conversations with the CPT Editorial Board and CMS to demonstrate the unique features or efficacy of the device and thus the need for favorable coding or payment changes. A temporary HCPCS can also help a manufacturer enter the market without delay. Without a device-specific code or assignment to an existing code, providers may need to use “miscellaneous/not otherwise classified” (NOC) codes, which are often denied by commercial payers.
Big Data and Class Imbalance in Medicare Fraud Detection
Published in Stuart H Rubin, Lydia Bouzar-Benlabiod, Reuse in Intelligent Systems, 2020
Richard A Bauder, Taghi M Khoshgoftaar
The Medicare Provider Utilization and Payment Data: Physician and Other Supplier (Part B) dataset, from 2012 to 2015, outlines information about physicians and the procedures they perform [28]. Each physician is denoted by his or her NPI and each procedure is labeled by its Healthcare Common Procedure Coding System (HCPCS) code [21]. The Part B data is aggregated (grouped by) the following: (1) NPI of the performing provider, (2) HCPCS code for the procedure or service performed, and (3) the place of service which is either a facility (F) or non-facility (O), such as a hospital or office, respectively. Some physicians can perform the same procedure (i.e., have the same HCPCS code) at both a facility and an office. Additionally, there are a few cases for which a physician is labeled as multiple physician types (or specialties), such as Internal Medicine and Cardiology. The Part B data, per year, is organized where each row contains the physician’s NPI and provider type (along with all non-changing physician information, such as name and gender) corresponding to one HCPCS code and further split by place of service (Office or Facility). Given this organization, all the procedure information corresponds to these four attributes. Therefore, for each physician, there are as many rows as unique combinations of NPI, Provider Type, HCPCS code, and place of service. For example, if a physician (NPI = 1003000126) has claimed 20 different procedures and three of them were conducted at both an office and facility (while the other 17 were conducted at one place), there would be 23 rows for this physician (assuming this physician is labeled as only one provider type).
A descriptive analysis of wheelchair repair registry data
Published in Assistive Technology, 2023
Alexandria M. James, Gede Pramana, Richard M. Schein, Anand Mhatre, Jonathan Pearlman, Matthew Macpherson, Mark R. Schmeler
The cleaning and extraction process had three sub-processes. The first process filtered out service ticket records with missing serial numbers. This was necessary to avoid potential duplication of cases as customers can get their devices repaired over time, several service tickets could be generated. A serial number can then be used to determine the number of service tickets and the number of repairs a device has over its lifetime. The second process attempted to determine devices’ age by purchase date and filter out the devices without one. A program written in C# language was developed to either decode purchase date from serial number or initiate web service calls to manufacturer’s website (if available). The third process categorized devices into HCPCS code categories based on device model. The HCPCS is a set of healthcare procedure codes primarily used for billing and identifying items and services. The fourth process then filtered out service tickets associated with devices older than 10 years. Devices older than 10 years are very likely to have incomplete repair records showing inaccurately low number of repairs. Devices that could not be categorized due to missing model information were excluded.
Accelerating the adoption of bundled payment reimbursement systems: A data-driven approach utilizing claims data
Published in IISE Transactions on Healthcare Systems Engineering, 2018
Wenchang Zhang, Margrét V. Bjarnadóttir, Rubén A. Proaño, David Anderson, Renata Konrad
Services rendered by medical facilities are coded using various coding systems: Current Procedural Terminology codes (CPT), which are maintained and copyrighted by the American Medical Association (AMA); Healthcare Common Procedure Coding System (HCPCS) codes, which are administrated by CMS; Primary Procedure Codes, which are maintained by the National Center for Health Statistics of the U.S. Public Health Service; and Revenue Codes, which are maintained by the National Uniform Billing Committee. We only utilize the PPC, CPT, HCPCS and revenue codes in our clustering algorithm, as together these codes summarize a patient's treatment and are the elements that drive the fee-for-service reimbursements.
Trends in wheelchair recommendations in a dedicated seating department
Published in Assistive Technology, 2020
The characteristics of the people who need complex equipment funded by Medicare in this study do not match the typical Medicare beneficiary. This is important to consider as some policy decisions within Medicare, such as the Healthcare Common Procedure Coding System (HCPCS) codes that label wheelchairs and accessories for coverage and payment, require consideration of the “national programmatic need” (HCPCS Decision Tree, 2018, p. 2). Without being in the majority, people who need complex equipment will be underrepresented in the current system. However, a separate benefit category may provide the opportunity to change the rules for this vulnerable population.