Know your DME billing process well

DME billing is a bit different when viewed along with the other genres of medical billing. A durable medical device (DME) provides therapeutic benefits to patients suffering from certain medical conditions and/or diseases. A DME is built for a medical purpose and can withstand regular use, suitable for home use. Regular DME items include:

  • Wheelchairs
  • Orthoses
  • Garlands
  • stools
  • Cranes
  • Compression sleeves

Surprisingly, however, despite the importance of DME billing, there is a lot of uncertainty. It’s a real shame that despite DME providers getting enough orders from doctors for supplies, they often struggle to recoup the expected revenue.

Different DME companies have different DME billing styles depending on frequency. Some companies bill regularly as needed, while others bill a few times a year. DME billing must be meticulous and accurate, as a single billing error on just one medical device can result in a loss of thousands of dollars for a DME salesperson.

To work on the loopholes in carrier/vendor DME billing, we need to understand the DME billing process.

DME Billing Process: A Brief Overview

Here are the main components of a typical DME billing process:

Recipe:
The primary requirement for DME billing is a rent/purchase prescription from the ordering physician specifying the quantity of the named DME.

Verification:
Verification of demographics and other patient information before submitting claims.

Credentials:
When DME suppliers invoice, they must meet the reference criteria before they can request a refund. Note: Billing for DME providers is sent to the DME provider and not the Medicare Part B provider. An exception, however, are covered plaster supplies.

Form:
The CMS-1500 is the appropriate form to process an invoice electronically.

Documentation:
Completion of the physician’s treatment plan documentation must be ensured, along with the time frame for using the DME.

Codes and modifications:
It is very important to apply the correct HCPCS codes, procedure codes, maintenance and repair modification codes. In the absence of an apt code, the E1399 or other HCPCS codes can be used. Note: A denial may result if HCPCS is used before a product’s lifespan has expired (generally 1-3 years).

Factory invoice:
A physical invoice (not sent electronically) must be included with the full description of the item, along with the medical necessity form signed by the physician. Note: All initial documents must be enclosed in one envelope and then submitted. Electronic processing cannot be started earlier.

Dates:
The date of injury (DOI) must be clearly stated. If necessary, include the Date of Service (DOS), which is the day the patient died or the day the patient stopped using the DME. Note: The service date is the date the patient receives the equipment. It is not the shipping date to be exact. The only exception is the cancellation of the order by a patient, where the date of the service becomes the date the equipment order is canceled.

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Supporting Documents:
Include the documents to support the necessity of the product, such as case notes, operation notes, LMN/CMN, product description, etc.

Coverage:
Coverage begins the day the device is delivered, set up/installed and ready for use by the patient at the desired location (usually at home) or at an experienced nursing home.

Repair claim:
Bill any claims for repair with a full explanation of the services.