According to bcbsnc.com, “Durable medical equipment (DME) is any equipment that provides therapeutic benefits to a member because of certain medical conditions and/or illnesses, and that can withstand repeated use, is primarily and customarily used to serve a medical purpose, and is appropriate for use in the home.” DME items include wheelchairs, cranes, orthotics, compression sleeves, slings, crutches etc. Further, some items are termed as ‘capped rentals.’ These are items that are used only for a short period of time where rental is more appropriate than a purchase.
DME billing process:
1) Prescription: For DME billing, a prescription is required for rent or purchase along with the quantity of the DME mentioned.
2) Verification: Verify the demographics and other data with the patient before filing for claims.
3) Credentials: In case of billing by a DME supplier, they must meet the credentialing requirement before applying for reimbursement. Apart from covered cast supplies, the billing for DME providers goes to the DME carrier and not to Medicare Part B carrier.
4) Form: Billing must be processed electronically on the CMS-1500 form.
5) Documentation: Ensure complete documentation with physician’s treatment plan along with the time frame of the DME to be used.
6) Codes and modifiers: Add the appropriate HCPCS codes, procedure codes, maintenance and repair modifier codes (in this order). Use E1399 or other HCPCS codes if an apt one does not exist. Also, a useful lifetime for a product is considered to be from 1-3 years. If the same HCPCS is used before this time passes, coverage can be denied (e.g. knee braces).
7) Factory Invoice: An invoice with complete description of the item, including the medical necessity form with the physician’s signature should be attached. However, this cannot go electronically with the claim form.
Note: All initial documents must be submitted in one envelope and only then processed electronically. This increases the accuracy and efficiency of the billing process.
8) Dates: Mention the date of injury (DOI) for better clarity. Also, if required, mention the DOS (Date of Service) which is the day the patient died or stopped using the DME.
9) Supporting documents: For ensuring the necessity of the product, documents such as chart notes, surgery notes, LMN/CMN, product description may be attached.
10) Coverage: This begins on the day the apparatus is delivered, setup/installed, and ready for use by the patient at the place desired (usually home) or sometimes could be a skilled nursing facility.
11) Repairs claims: If any claims for repair exist, bill it with an entire explanation of the services.
Usage of dashboards and other software reporting tools can enable easy to access data, check on the held A/R, payments and denials, and comprise a detailed analysis on the increase in revenue and merchandise profitability. To ensure higher revenues, a better procedure for the physician is to dispense the DME from their practice rather than from a DME provider.
Check if the guidelines are aptly followed by your DME staff in order to avoid errors and get fully reimbursed.