When a DMEPOS manufacturer/distributor entity is dissatisfied with a PDAC HCPCS Level II coding decision, a reconsideration request may be submitted if the following criteria is met.
- Additional information is submitted regarding product’s features/functions that was not included with original Coding Verification application, or
- Evidence is provided that product’s design has changed since original request was submitted
In addition to the above met criteria, the below requirements apply as well.
- Entity must submit request within 45 days of the Coding Verification Determination letter date
- If beyond 45 days, a new application is required
- Requests must provide evidence to substantiate a reconsideration of the PDAC’s original coding determination. Reconsideration requests that do not meet the criteria outlined above will be denied a coding reconsideration
- Only a single product per application will be evaluated. Do not submit a single reconsideration request for multiple products
- Variations in color, size, etc. for a product are considered as a single product for this purpose
- Exception: Surgical Dressings containing same composition but in multiple sizes must have a sample for each size and requested HCPCS code submitted for review
- If product has changed from prior application submission, a new application is required
Request Must Include
- A completed Reconsideration Request Form submitted by a valid submitter/requestor
- Valid submitter/requestor is defined as product manufacturer point of contact or designated representative. Designated representative is an independent entity manufacturer has assigned to represent their company
- Detailed documentation to support a code change, that has not been previously submitted to the PDAC
- Documentation if Minimum Lifetime Requirement has changed
Request will be Rejected When
- It is not submitted by a valid submitter
- It is incomplete or missing required information
- It is to change product coding assigned by the CMS HCPCS Workgroup
- It is to create or revise DME MAC or CMS coding guidelines
- It conflicts with existing DME MAC or CMS benefit category and coding instructions
Request Acknowledgement and Completion Notification
- The PDAC will determine if request is valid within 15 days of its receipt and will notify submitter via email
- If submitter does not hear from the PDAC within 15 days, call the PDAC Contact Center
- Submitter is notified via email of review results along with decision rationale
- HCPCS Code Product Classification List will be updated as necessary
CMS HCPCS Workgroup
Within CMS, there is a CMS HCPCS Workgroup comprised of representatives of the major components of CMS, as well as other consultants from pertinent Federal agencies. The CMS HCPCS Workgroup is responsible for maintaining the permanent, national HCPCS Level II codes. If a HCPCS Level II code does not exist for a particular product, if the description for an existing code is not adequate or appropriate, or, an existing code needs to be deleted, any interested party may submit a request to the CMS HCPCS Workgroup to modify the HCPCS.
To submit a request to the CMS HCPCS Workgroup, complete and send the application available on the CMS HCPCS - General Information webpage to the CMS HCPCS Workgroup Coordinator at the address below.
Centers for Medicare & Medicaid Services
Kimberlee Combs-Miller, CMS HCPCS Workgroup Coordinator
7500 Security Blvd
Baltimore, Maryland 21244-1850
The PDAC Contested Reconsideration Application process provides a mechanism for an entity other than a product’s manufacturer to challenge the assigned HCPCS code. The process begins with submitting a Contested Reconsideration Application for the product. Careful attention should be made by the submitter’s rationale for the changing the assigned code. View Contested Reconsideration Request webpage for details.