DME documentation guidelines can appear overwhelming at first, especially with constant industry changes. The good news is by learning foundational billing principles, it will help you to navigate the billing industry with more accuracy and confidence. This article answers some of the most frequently asked questions about documentation guidelines for durable medical equipment to help you achieve billing success.
What are the Documentation Guidelines for Durable Medical Equipment?
For DME items to be covered, a patient’s medical records must contain the details of their medical condition and explain why the item is essential for their daily life. These data types can include various documents from hospital visits, nursing home stays, health care professionals’ records, prescriptions, clinical documentation, and more.
5 Common Questions Providers Ask About DME Documentation Guidelines
Here are some common questions asked to help you better understand DME documentation guidelines.
Question: What is the purpose of the document instructions?
Answer: These guidelines ensure that the equipment the patient is ordering is medically necessary. Various types of paperwork help to support why an item is crucial for the patient’s daily life.
Question: Does a prescription need to be provided before the DME order can be fulfilled? What should it include?
Answer: Yes, you must receive a prescription from the doctor before fulfilling the order because prescriptions are necessary for billing claims. The accompanying documents should also include the following data.
- Provider’s plan of treatment
- Anticipated benefits the equipment will provide the patient
- Patient’s clinical and functional status
Question: What are the most frequently used modifiers for claims?
Answer: Claim modifiers provide details about how the patient will use DME and the length of that use.
- EY – No physician order
- GY – Non-covered item
- KH – Initial claim, first-month rental
- KI – Second and third capped rental months
- KJ – Fourth to 13th capped rental months
- KX – documentation to support medical necessity
- MS – Maintenance and servicing
- NU – New equipment
- RA – Replacement of DME, orthotic, or prosthetic item
- RR – Rental
- RT/LT – Right/left
- UE – Purchase of used equipment
Question: Why would my claim be denied and labeled as not medically necessary?
Answer: There are several reasons why your claim could be marked as not medically required. The two most common reasons are audits and diagnosis codes.
- If a claim is audited and the insurance company realizes it lacks sufficient data (even if it was already paid), you’ll need to resubmit all documentation showing the item was medically necessary.
- The second reason is that the diagnosis codes, modifiers, or other data were incorrect (typos, outdated information, etc.).
Question: Since data errors are a large part of claim denials, what are some tips to help reduce errors?
Answer: Here are some steps you can take to prevent mistakes from occurring with your claims.
- Thoroughly review the claims process from intake to submission for mistakes
- Examine why your claims were denied and the reasons
- Have your team proactively examine the claim for data errors before submission.
- Repeat the above steps as needed throughout the year
There are many resources available to help educate you on documentation guidelines for durable medical equipment; a few are listed below for your reference.
- Noridian Healthcare Solutions Customer Service and Claim Submission FAQs
- Noridian Healthcare Solutions Billing Situations
- Medicare Program Integrity Manual
- DME Documentation Requirements for DME Providers
Learn How a DME Billing Company Can Increase Your Claim Approvals
Working with Medbill, a trusted and experienced DME billing company, can help you create and maintain a well-structured billing system that leads to increased claim approval rates and timely payments. Contact our team to learn how we can help improve your monthly collections.