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Categorization of a Universal Coding System to Distinguish Use of Durable Medical Equipment and Supplies in Pediatric
Arda Hotz1,2, Eli Sprecher1,2, Lucia Bastianelli3
1Complex Care, Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts.
Insights
Durable medical equipment and supplies (DMES) use was analyzed in over 4.5 million pediatric Medicaid patients. Prevalence reached 17.1%, with spending averaging $593 per year, increasing significantly for those with complex chronic conditions.
Area of Science:
- Pediatric Health Services Research
- Medical Economics
- Health Informatics
Background:
- Durable medical equipment and supplies (DMES) are crucial for pediatric patient health and function.
- Limited data exists on the prevalence and financial impact of DMES utilization in children.
- Understanding DMES use is vital for optimizing care and resource allocation in pediatric populations.
Purpose of the Study:
- To categorize Healthcare Common Procedure Coding System (HCPCS) codes for durable medical equipment and supplies (DMES) in pediatrics.
- To determine the prevalence of DMES use among pediatric Medicaid beneficiaries.
- To analyze Medicaid spending associated with DMES for children and adolescents.
Main Methods:
- Cross-sectional analysis of the 2018 Merative Medicaid Database, including over 4.5 million pediatric patients (0-21 years) across 12 states.
- Categorization of 2576 HCPCS DMES codes into 164 DMES types and 14 organ systems by pediatricians and expert reviewers.
- Statistical analysis using chi-squared and Wilcoxon rank sum tests to compare DMES prevalence and per-member-per-year (PMPY) spending, stratified by complex chronic conditions (CCCs).
Main Results:
- Overall DMES prevalence was 17.1%, significantly higher in patients with complex chronic conditions (up to 60.9%) compared to those without (10.1%).
- Average PMPY DMES spending was $593, escalating from $349 (no CCCs) to $4253 (≥2 CCCs).
- Common DMES included enteral supplies, diapers, orthotics, wheelchairs, and oxygen for children with CCCs; lenses and vision frames for those without.
Conclusions:
- The Healthcare Common Procedure Coding System (HCPCS) effectively distinguishes various durable medical equipment and supplies (DMES) types and usage patterns in pediatric Medicaid populations.
- DMES utilization and associated spending are significantly higher among children with complex chronic conditions, highlighting a critical need for targeted resource management.
- Further research is recommended to evaluate the utility of the HCPCS DMES categorization for enhancing the quality and safety of durable medical equipment and supplies.
Importance:
Although durable medical equipment and supplies (DMES) are commonly used to optimize the health and function in pediatric patients, little is known about the prevalence of use and spending on DMES.
Objective:
To categorize the Healthcare Common Procedure Coding System (HCPCS) for distinguishing DMES types, and to measure the prevalence and related spending of DMES in pediatric patients using Medicaid.
Design, Setting, And Participants:
This study is a cross-sectional analysis of the 2018 Merative Medicaid Database and included 4 569 473 pediatric patients aged 0 to 21 years enrolled in Medicaid in 12 US states from January 1 to December 31, 2018. Data were analyzed from February 2019 to April 2023.
Exposure:
DMES exposure was identified with the Centers for Medicare & Medicaid Services HCPCS codes. Three pediatricians categorized HCPCS DMES codes submitted by vendors for reimbursement of dispensed DMES into DMES types and end-organ systems; 15 expert reviewers refined the categorization (2576 DMES codes, 164 DMES types, 14 organ systems).
Main Outcomes And Measures:
The main outcome was DMES prevalence & Medicaid spending. The χ2 test was used to compare DMES prevalence and Wilcoxon rank sum tests were used to compare per-member-per-year (PMPY) spending by complex chronic conditions (CCC).
Results:
Of the 4 569 473 patients in the study cohort, 49.3% were female and 56.1% were aged 5 to 15 years. Patients used 133 of 164 (81.1%) DMES types. The DMES prevalence was 17.1% (95% CI, 17.0%-17.2%) ranging from 10.1% (95% CI, 10.0%-10.2%) in patients with no chronic condition to 60.9% (95% CI, 60.8%-61.0%) for patients with 2 or more CCCs. The PMPY DMES spending was $593, ranging from $349 for no chronic condition to $4253 for 2 or more CCCs. Lens (7.9%), vision frames (6.2%), and orthotics for orthopedic injury (0.8%) were the most common DME in patients with no chronic condition. Enteral tube / feeding supplies (19.8%), diapers (19.2%), lower extremity orthotics (12.3%), wheelchair (9.6%), oxygen (9.0%), and urinary catheter equipment (4.2%) were among the most common DMES in children with 2 or more CCCs.
Conclusions And Relevance:
In this cross-sectional study, HCPCS distinguished a variety of DME types and use across pediatric populations. Further investigation should assess the utility of the HCPCS DMES categorization with efforts to optimize the quality and safety of DMES use.
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