Items of DME (Durable medical equipment) that is deemed necessary for medical reasons come under Part B of Medicare. These items need to be long lasting and be good for a minimum of 3 years, and the doctor prescribing such equipment needs to fill out a detailed order in writing. Some commonly prescribed durable medical equipment include commodes, oxygen equipment, continuous passive motion (CPM) machines, crutches, special hospital beds, lifts, traction equipment, walkers, and more.
Most of the Orthotic and Prosthetic claims end up being denied because of documentation that contains errors. Durable medical equipment billing services providers need to ensure that the DME insurance verification procedure is followed so that the physician receives the correct reimbursement due for services rendered. According to a review conducted by the American Orthotic and Prosthetic Association National Assembly a couple of years ago, error rates were found to be high for lower limb orthoses and lower limb prostheses for Region A and B, and were low for B and D. Medical records were the culprits for lower limb orthoses claims, it was the replacement records that were responsible for errors found in lower limb prostheses claims.
DME billing companies should know that whenever an error is detected in a claim, the CERT contractor sends the claimant an excess payment demand letter. In order to appeal this, the claimant should make sure a redetermination is filed within 120 days, here are some highlights:
- A large quantity of orders gets denied as they are not legible enough. The patient’s doctor or nursing practitioner needs to provide a photocopy of the DME order, or a fax image, or the original document in ‘pen and ink’.
- Any verbal dispensing order needs to be followed up with a written order in detail and should include the description of the DME item. It should also have the physician’s name, the beneficiary’s name, order date, start date, as well as the signature of the prescribing practitioner.
- Any claim that is submitted without an order must have an EY modifier, which indicates that there is no qualifying healthcare professional to provide the order. The practitioners are responsible for keeping the order error rates down.
- The medical records of the patients should always justify the care being provided, along with sufficient documentation.
- Medical history should include co-morbidities arising out of amputation, the necessity for use of ambulatory assistance, detailed examination reports of musculoskeletal and neurological conditions.
- HCPCS codes and DME procedures along with modifiers in claims are crucial in DME billing and the description in the physician’s notes should match the codes selected by the prosthetist.
Durable medical equipment billing companies should be aware that Medicare covers repairs and replacement parts for DME items. However, Medicare pays only 80% of the approved amount for purchasing the DME item. Medicare also reimburses 80% of the expenses incurred for repairs or such DME items, which includes replacement costs as well. However, the justification for the repair needs to be provided by thorough proper documentation by the supplier or physician. The various codes are:
- L7510 for the repair of prosthetic devices, including repairs and replacement of minor parts.
- L7520 for repairs to prosthetic devices including the labor component (per 15 minutes)
- L4210 for repairs to orthotic devices, including repairs and replacement of minor parts.
- L4205 for repairs to orthotic devices including the labor component (per 15 minutes)
Thus with ways in which errors can be avoided must be adhered to, however more important is to be aware of the possible errors.
DME billing companies should note that the labor code can be applied for the actual time involved for genuine repairs, or medically required adjustments that were carried out 90 days after delivery/installation.