DME billing

  • DME Billing Services
    How to order DMEPOS items correctly?

    How to order DMEPOS items correctly?

    As per the Medicare Program Integrity Manual, Chapter 5 (Items and Services Having Special DME Review Considerations), before you dispense any DMEPOS item to a beneficiary, you need to have an order from the treating physician. Please note that this article is intended for suppliers billing Durable Medical Equipment (DME) MACs for Durable Medical Equipment Prosthetics, Orthotics Supplies (DMEPOS) provided to Medicare beneficiaries. Verbal or preliminary written orders: Suppliers may dispense most items of DMEPOS based on a verbal order or a preliminary written order from the treating physician/practitioner. Detailed written orders required before claim submission: A detailed written order may be a photocopy, facsimile image, electronic, or pen-and-ink original document. For all items, the supplier shall have a detailed written order prior to submitting a claim. It needs to have a description of the item to include all options or additional features that will be separately billed, or that will require an upgraded code. The description can be either a general description (for example, “wheelchair or hospital bed”), a brand name/model number, an HCPCS code or HCPCS code narrative. It must include the beneficiary name, the date of the order, and the physician/practitioner signature. If it is for a drug provided…

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  • DME Billing Services
    Physician Liability for DMEPOS Medical Necessity

    Physician Liability for DMEPOS Medical Necessity

    The Medicare program only pays for health care services that are medically necessary. In determining what services are medically necessary, Medicare primarily relies on the professional judgment of the beneficiary’s treating physician, since he or she knows the patient’s history and makes critical decisions, such as admitting the patient to the hospital; ordering tests, drugs, and treatments; and determining the length of treatment. In other words, the physician has a key role in determining both the medical need for, and utilization of, many health care services, including those furnished and billed by other providers and suppliers. Physicians are required to certify to the medical necessity for any service for which they submit bills to the Medicare program. Physicians are involved in attesting to medical necessity when ordering services or supplies that must be billed and provided by an independent supplier or provider. Medicare requires physicians to certify to the medical necessity for many of these items and services through prescriptions, orders, or, in certain specific circumstances, Certificates of Medical Necessity (CMNs). These documentation requirements substantiate that the physician has reviewed the patient’s condition and has determined that services or supplies are medically necessary. Two areas where the documentation of medical…

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  • How to become DME Supplier for Medicare?

    The regulation of businesses providing Durable Medical Equipment (DME) or Home Medical Equipment (HME) is dependent upon the types of equipment, as well as the jurisdiction. Since the term DME covers a wide array of devices, from crutches to catheters to wheelchairs to blood glucose monitors, it may not always be clear for businesses whether they must be licensed in a particular state. Furthermore, additional permitting may be required for certain types of equipment (e.g., a Pharmacy License for oxygen-related devices). DME suppliers are governed by stringent federal and state laws, particularly those that participate in the Medicare/Medicaid program. Initially, if a license is determined to be required, a DME company must obtain an “in-state” or a “resident” license. This generally requires an extensive application, varying fees, proof of insurance, and an inspection, which is usually scheduled upon approval of the application. If the company wishes to expand into another state, it must obtain an “out-of-state” or a “non-resident” license in that state. This process is more of the same, but also may require verification that the business currently holds a resident license (or proof that a license is not required) in the home state. Medical practitioners and medical service…

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  • Common Modifiers for DME

    When billing for durable medical equipment (DME), use the appropriate HCPCS code and modifier(s) to describe the items being billed. Also, include an ICD-9/ICD-10 diagnosis code indicating the medical condition for which the item has been prescribed. In addition to an appropriate HCPCS code for the DME item, many HCPCS codes require a modifier. The modifiers are used to provide more information about the item. For example, the modifier may tell HMSA that an item is new, used, or rented on a capped basis. For capped rentals, modifiers distinguish which month’s rental is being billed. If these modifiers are used incorrectly or missing, the claim may be denied. To expedite processing of your claims, please indicate the first-month rental by including the appropriate modifier code, and bill your claims in sequential order. Inexpensive or Routinely Purchased DME Inexpensive DME-This category is defined as equipment whose purchase price does not exceed $150. Routinely Purchased-This category consists of equipment that is purchased at least 75% of the time. Payment for this type of equipment is for rental or lump-sum purchase.  The total payment may not exceed the actual charge or the fee for purchase. Common modifiers used in this category are: RR…

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  • DME Billing Services
    3 Tips to Analyze Payer Reimbursement for DME

    3 Tips to Analyze Payer Reimbursement for DME

    Some things in life are very easy and straightforward. Unfortunately, purchasing things such as splints, prosthetics, and durable medical equipment (DME) – and determining which orthotics are covered by insurance – isn’t so cut and dried. In fact, a lot can go wrong when it comes to orthotics and prosthetics billing. So, to make sure your patients get with they need – and you get paid what you deserve – stick to the following guidelines. The information below refers to how Medicare reimburses for prosthetics and orthotics and does not necessarily reflect how commercial payers reimburse for these interventions. At the same time, many commercial insurance payers align themselves with Medicare policies, so this should serve as a good general guide. For prosthetics, Medicare reimbursement includes evaluation, fitting, parts and labor, repairs due to normal wear or tear within the first 90 days of the delivery date, and adjustments made during fitting and within the first 90 days of the delivery date (not including adjustments brought on by changes in the remaining limb or a patient’s level of function). For orthotics, Medicare reimbursement includes evaluation, measurement and/or fitting, fabrication and customization, materials, cost of labor, and delivery. HCPCS Code and…

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  • DME Billing Services
    Specialization consideration for DME suppliers in medical billing and coding

    Specialization consideration for DME suppliers in medical billing and coding

    Durable medical equipment billing is the process by which insurance companies are charged for the services provided to their clients. And in order to achieve the complete reimbursement dollars billing codes that represent different aspects of the DME process are implemented. The characters the biller enters relate to different aspects of a diagnosis or procedure and allow the information to be uploaded for billing without having to manually define either diagnosis or procedure. This allows the process to be implemented faster without having to describe everything in detail. When we talk about specialization consideration in DME suppliers’ one specialty that often crosses the supplier’s path is Orthopedics. Orthopedic facilities often provide patients with supplies, such as casts and canes, which is integral to patients’ treatment plans. What DME supplies can be used for an orthopedic treatment and how to charge for them? The Current Terminology Codes (CPT) published in the American Medical Association’s are used for professional DME coding. These codes are frequently known as Level I of the Healthcare Common Procedure Coding System (HCPCS). DME suppliers are categorized as Level II HCPCS codes and are recognizable by their alpha-numeric structure. Just like CPT codes, Level II HCPCS codes are…

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  • DME Billing Services
    Critical factors to consider before you outsource DME billing and coding

    Critical factors to consider before you outsource DME billing and coding

    Durable Medical Equipment (DME) as a healthcare industry field is different from other specialties and so is its medical billing and coding requirements. You need an in-depth and specialized knowledge of all the updated HCPCS Level II codes as DME claims are classified under HCPCS Level II. And as to speak about DME suppliers, the complex nature of reimbursement is another challenge they constantly face. Since patients can rent the expensive equipment rather than purchase, DME billers and coders must be conscious of exactly how to code claims and when to send them for getting the precise reimbursement amounts. What this means is that the code should lay down the equipment was rented and not purchased. The rental period should be recorded separately on the claim so that the insurance company will pay a small reimbursement for each of those days. Outsourcing your DME medical billing tasks facilitates a smart solution for your hospital billing requirements, assisting you to organize the entire billing and collection process at a portion of your current operating costs. If you want to make the in-house workload a bit lighter, it’s a great idea to consider outsourcing your DME billing. Here are some important ways…

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