Digging Deep in DME coding: External Elements that streamline your Medical Billing

Medical billing and coding from the outside may look like an easy on the run job, but it has much more intricacies that what you can imagine. The Durable Medical Equipment charges, which have different ‘codifications’, altogether are is making life worse for DME owners to sustain a streamlined revenue cycle, as most of the claims are being denied or delayed due to incorrect coding or billing information.

The moot question that arises here is how can DME suppliers go to the root cause of the daily coding issues. Can they use external elements to streamline their entire billing cycle and aging AR days? Let’s find out.

If you are into medical billing and coding, durable medical equipment may scare you as its coding complexities are deeply rooted in HCPCS or Healthcare Common Procedure Coding System Level II codes and Medicare’s policies. Not to worry, as there are many ways to fine-tune your DME coding abilities by digging into the DME and exploiting how to properly assign HCPCS Level II codes for billing. Firstly, one needs to start by getting their hands dirty and scooping away the top layer of DME by defining it. Next, you need to dig deeper to find Medicare’s policies on DME and discover the doctor’s role in getting reimbursed. And finally, you shall unearth how to use particular codes to support medical necessity.

Policies for DME Codes

  • Remember that any time you use an HCPCS Level II code that ends in 99, such as, E1399 Durable medical equipment, miscellaneous, provide supporting documentation to bill that code.
  • Once Medicare receives a miscellaneous code, the claim is suspended and medical records are requested. The records are then checked for several possible issues.
  • Next, the miscellaneous code is reviewed to see if another code is more appropriate to the bill.
  • Also, keep in mind that most medical gears have a code appointed. If the piece of equipment does not have a code assigned, then the manufacturer’s invoice is reviewed for an allowable.
  • In the final stage, the medical necessity is verified before payment is made.

If the in-house billers are facing a dilemma regarding code for a particular item you can check with Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC). Their guidance to manufacturers and suppliers on proper usage of HCPCS codes in regards to DMEPOS services identified for Medicare billing.

A Doctors role for DME Supplies

If you work in a doctor’s office you may wonder how it impacts you. An order from the presiding doctor is required for a beneficiary’s DME supplies. According to Medicare regulations, a doctor order, certificate of medical necessity (CMN), or attestation from a physician, alone, does not show medical necessity (You can check the mentioned details on CMS Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.7 for additional information).

To dig deep into the DME coding the service provider contacts your office to request medical records to support medical necessity. The medical records consist of office notes, X-rays, laboratory results, hospital notes (including emergency room visits), outpatient services, inpatient stays, and therapy services. When gathering data in the physician’s office for a provider review the section and submit any other documentation requested.

In the next step, the provider is notified when a claim is denied or upheld at the redetermination level. This notification includes submission instructions for the next level of appeal. During the assessment at the reconsideration level, the providers don’t always submit additional information. Without additional data to support medical necessity, the reconsideration level must uphold the denial. Remember that documentation is a very important part of a beneficiaries chart, and if one wants to dig deep into DME codes here are the final words ’ If you don’t document it, it wasn’t done.’