Unlike traditional medical billing and coding, the durable medical equipment (DME) industry is thoroughly regulated. At the same time, any minor mistakes can result in an unpaid claim. Since most providers bill DME claims to Medicare services, their billing staff must constantly check all Medicare DME documentation requirements before claim submission.
This article will provide you with valuable information about what you need to know for Medicare DME billing compliance.
What You Should Know about Billing DME to Medicare
Before learning about the billing guidelines and requirements, you should understand some main points when billing DME to Medicare.
- Billing Medicare is similar to third-party billing payers, except:
- It’s a government program.
- You’re responsible for submitting correct claims.
- You must be an official Medicare contract supplier.
- Medicare claims are processed by Medicare Administrative Contractor (MAC), who examines and determines if the claims meet medical necessity guidelines.
- If you’re billing Medicare Part B, the process is similar to third-party payers.
- Medicare and the patient both pay Part B claims (typically an 80/20 breakdown)
- If you’re billing Medicare Part C, you’re simply billing a different payer. Instead of billing to the DME MACs, you’re billing to the commercial insurance.
- Commercial insurance will process and pay the claim.
- Centers of Medicare and Medicaid Services (CMS) pay the MCOs to administer the insurance for those beneficiaries.
Medicare Documentation Guidelines
For CMS to ensure their programs operate effectively, DME providers must meet the Medicare DME documentation requirements to secure payments. Below are the Medicare documentation billing guidelines to aid the billing process.
- All suppliers should have documentation on file that proves medical necessity. For example, medical records from hospitals and doctor’s offices.
- Records should verify that the equipment or services were “reasonable and necessary.”
- If Medicare pays claims with insufficient documentation, they might consider it an overpayment, and they can partially or fully recover their money.
- All medical information provided must be legible and include the physician’s signature.
- All documents need to be clear, concise and reflect the patient’s condition.
- Progress notes must be dated and signed by the examiner.
- The DME provider is responsible for providing “proof” that equipment was medically necessary.
Medicare DME Documentation Requirements
Medicare DME documentation will vary depending on the patient, type of equipment needed, if the patient buys or rents the item, and how long the patient will use the item. For all claims, the patient’s medical records should be readily available. The following list are examples of information in the patient’s records to show medical necessity.
- Reason for doctor’s visit
- Patient history
- Visit findings assessment and diagnosis
- Tests conducted with the results
- Date of the visit
- A detailed plan of care with signature
- Proof of a healthcare professional prescribing the equipment and treatment
- Level of care needed
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