An Introductory Review of CMS’s DME Billing Guidelines

There are guidelines and regulations for you to follow for billing durable medical equipment (DME) items. The Centers for Medicare and Medicaid Services (CMS) is a U.S. federal agency that provides health coverage to many Americans. They work with state governments to oversee the Medicare program. The CMS creates and manages DME billing guidelines, including working with other organizations on claims audits to ensure the distribution of proper payments.

Continue reading to understand CMS’s DME billing guidelines on commonly used words, an overview of the billing guidelines, and how you can stay current on the changing rules and regulations. 

Read our article on How to Become a DME Supplier for Medicare and Supply DMEPOS if you’re interested in becoming one. 

Terminology Used in CMS DME Billing Guidelines

Before you begin billing DME, you’ll see some common words and phrases throughout the billing process. Here are several terms and what they mean to help you along the way. 

  • DME and HME – Durable medical equipment or home medical equipment are items that can be used repeatedly by a patient in their home
  • DMEPOS – Durable Medical Equipment, Prosthetics, Orthotics, and Supplies are items that can be used repeatedly by a patient in their home 
  • Beneficiary – A patient who receives Medicare benefits
  • HCPCS Level II Codes – Five-digit billing codes that will begin with a letter with additional letters and numbers that follow 
  • Modifier – Two-letter codes that can provide more information about the HCPCS code being billed
  • CMN – Certificate of Medical Necessity is a form that documents the patient’s medical necessity for DME
  • NSC – National Supplier Clearinghouse assigns supplier numbers to DME suppliers so they can bill DME
  • OIG – Office of Inspector General, an organization responsible for working with Medicare’s fraud units to investigate fraud and abuse
  • UPIN – Unique Physician Identification Number, an individual number assigned to each provider who bills Medicare
  • Clean Claim – A claim that’s free from errors and submitted on time to ensure timely payments 
  • CMS 1500 – A form needed to submit medical claims to Medicare and Medicaid

To learn more about CMS’s acronyms and terminology, click here.

DME Billing Guidelines Overview 

The CMS billing guidelines for DME is a very lengthy process that requires a knowledgeable DME billing team to complete. Therefore, the below information is a straightforward overview and isn’t a detailed set of instructions. To read in-depth instructions on CMS’s DME billing guidelines, click here

Become a Contract Supplier 

You must become an official Medicare supplier to bill DME claims. 

Required Medical Documentation to Show Medical Necessity 

The accurate documentation needed to submit a DME claim will vary depending on the order. In general, here are the requirements for every claim submission.

  • Medical records
  • Physician’s progress notes
  • Patient care plan
  • DME prescription
  • Patent’s insurance and billing information

Billing the Claim

Indicate the HCPCS Level II codes and modifiers on all paperwork. It’s important to note that every item needs to be assigned a code.

Follow Up on Claims

You can follow up on all your claims to make sure they are approved. If not, you will be required to resubmit the claim with the corrections indicated. 

Medicare Requirements for Providers 

Read this article on Medicare DME Documentation Requirements for Providers to guarantee your claims are meeting Medicare DME billing compliance.

Stay Up to Date on CMS DME Billing Guidelines Changes

As mentioned earlier in this article, the DME industry constantly changes its rules and regulations. Make sure you and your team stay current on all changes before submitting claims to ensure your timely payments. Here are some resources you can use to monitor CMS changes.

Learn More About Medbill 

Medbill is a full-service, 100% U.S.-based DME billing company. Our team dedicates themselves to helping DME providers and suppliers with their billing needs. We can assist with document review, claims submission, daily billing activities, A/R, and more. 

Contact us to learn how we can help you bill DME claims.