What They Won’t Tell You When You Search “How to Bill DME”

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What They Won’t Tell You When You Search “How to Bill DME” 

Valuable information on billing DME, HME, and DMEPOS equipment

 

Executive Summary 

Learning how to correctly bill durable medical equipment (DME), home medical equipment (HME), and durable medical equipment prosthetics, orthotics, and supplies (DMEPOS) items is a complex and lengthy process. Learning this information from a tutorial is difficult as it is usually a broad approach to DME billing. Having an educated staff or outsourcing company work alongside the billing team can help meet proper requirements resulting in higher claim approvals and payments. 

 

Download a printable PDF copy of this white paper.

 

Vital Pieces to the DME Billing Process  

The billing steps for DME, HME, and DMEPOS equipment is a complex and lengthy process. For this reason, DME providers hire trained billing specialists who are familiar with the DME industry and can accurately submit claims while communicating with patients, medical professionals, and insurance companies. 

 

Here are some vital pieces that DME billing specialists need to include in the DME billing process. 

  • HCPCS Code – explains what item(s) the patient needs 
  • Modifier(s) – describes the item(s) being billed
    • Bill the modifiers with HCPCS codes based on payer requirements
  • ICD-10 Diagnosis Code – indicates patient’s medical condition 

 

DME Billing Requirements & Medical Review Information

When billing for DME, insurance companies and Centers for Medicare and Medicaid Services (CMS) have specific requirements for claims to be approved. Any deviation from that process could result in a denied or rejected claim. 

 

Some billing requirements include:

  • CMS Claims – Correctly formatted 837P EDI claim, or a typed CMS-1500 (version 08/05) form.
  • Capped Rentals – Certain items are rentals only or must be rented first before purchasing.
  • Claim Repairs – Need to include a description of services provided.
  • E1399 and Miscellaneous HCPCS Codes – Can only be used if no appropriate HCPCS billing code is available. If used, include:
    • Description of the item
    • Submit a manufacturer invoice
    • Include a certificate of medical necessity with the physician’s signature (if needed)
    • Do not staple to the claim form 
    • Submit as paper documentation or submit claim and documentation on appropriate payer portal

 

It’s important to note that any DME, DMEPOS, or HME items that are not authorized in advance (if approved in advance, a certification number is provided) will undergo a medical review. Therefore, include the following as part of the claims submission process to help speed up approval.

 

  • Plan of treatment
  • Anticipated time length for needed equipment 
  • Expected outcomes from needed equipment (per the physician) 
  • Physician’s involvement for the patient using the equipment 
  • Show medical necessity with a description of the patient’s health and treatment status 

 

CMS Claim Information by State

To obtain specific information by the business’s state, CMS created four Medicare Administrative Contractor (MAC) jurisdictions that specially process DMEPOS claims.

 

  • DME MAC Jurisdiction A
  • DME MAC Jurisdiction B
  • DME MAC Jurisdiction C
  • DME MAC Jurisdiction D

 

For the most current list of states and their assigned jurisdiction, visit CMS.gov.  

 

CMS’s Local Coverage Determinations for DMEPOS

There are precise requirements when submitting claims for DMEPOS to Medicare beneficiaries. To help clarify the requirements, CMS required the DME MACs to develop 57 DMEPOS Local Coverage Determinations (LCDs) for providers. 

 

Before dispensing any equipment, some document expectations include:

  • Extensively review if the beneficiary qualifies for the equipment.
  • Maintain communication between the DMEPOS supplier and ordering physician. 
  • All medical documentation must come from a medical record.

 

Billing Information You Won’t Find Online 

While the above information provides excellent guidance, insurance companies’ and CMS’s exact requirements are dependent on the DME provider’s product mix, business state, and payor groups. That information is difficult to obtain online due to its specific nature, which requires DME providers to invest in resources to find and receive this information. Without thoroughly understanding, DME billing requirements can result in higher denials and a much lower collection percentage. 

 

That’s when investing in outsourcing billing experts, like Medbill, can make all the difference. Medbill is an experienced DME billing company with a staff that is experts in the DME industry. In addition, each Medbill customer has a dedicated team who focuses on achieving the customer’s goals, including increasing collection rates, decreasing DSO, and increasing claim approvals.  

 

Conclusion

DME billing information is difficult to obtain online, which requires significant investment in learning and implementing the proper guidelines. The Medbill team can work alongside current staff to train them on DME, HME, and DMEPOS billing requirements to increase clean claims resulting in higher collection percentages.