Demystifying Medicare: DME Coverage Essentials and Basic DME Billing Tips

Are you struggling to understand the DME billing business? Are the constant changes in the billing rules and industry mandates confusing you too?
If yes, worry no more. You are not alone in this.

Today, there are more than 50 % of DME providers suffering from the same fate.

Running a healthcare practice is not an easy matter, and understanding its billing affairs, with the constant changes in regulations and requirements, can be quite a struggle for many. Plus, the constant appearance of new codes and changes in the policies of Medicare and Medicaid, make it no easier.

Here is a brief understanding of the different components of Medicare and some crucial insights into DME billing considerations that one should be aware of.

How to Bill Medicare for DME Supplies

Below are some suggestions and guidance to assist you in initiating a seamless billing process for DME supplies through Medicare. It is not only crucial to consistently adhere to the latest rules and regulations in the industry to ensure accuracy, but also to submitting claims in a timely manner for faster reimbursement. In fact, one of the best ways to stay ahead of the present regulations in the DME billing space is regularly checking the Centers for Medicare and Medicaid Services (CMS) website for any modifications.

  • Demonstrate the proof of necessity for the DME equipment – Every document accompanying a claim must demonstrate medical necessity. As the provider, it is your responsibility to furnish Medicare with evidence that the item is medically necessary for the patient. Below are several documents that can help you support the DME’s “reasonable proof of necessity” status:
  1. Hospital and physician medical records
  2. Prescription orders from a medical professional
  3. Certificate of Medical Necessity endorsed by both the medical professional and DME provider
  4. Signed and dated progress notes
  • Inspect Documents – It is mainly done for legibility regardless of whether you are submitting an electronic or a paper-based claim. It is imperative that all documents are legible. This is because Medicare will not accept unclear information lacking a physician’s signature. Therefore, make sure a thorough review of the documentation is done efficiently, and request fresh copies for any illegible content.
  • Ensure transparency and clarity – Avoid submitting information with the mere hope of meeting medical necessity criteria. Every submission should be logical, clear, concise, directly relevant to the patient’s condition and important for the patient’s need.
  • Verify all the current DME codes and modifiers – Prior to claim submission for payment, it is extremely essential to verify that the equipment is coded correctly with up-to-date HCPCS Level II codes and includes the relevant modifiers. Also every DME coder must ensure:
  1. HCPCS Level II codes align with the ordered DME
  2. Modifiers encompass all necessary information pertaining to the item
  • Submitting claim documentation timely – When it’s time to submit the DME claim to Medicare, you will need to utilize the CMS-1500 form (also referred to as HCFA 1500). Claims should be electronically submitted to Medicare. CEDI serves as the Medicare contractor for electronic claim submissions to Medicare. If you qualify as a small supplier, there might be exceptions to electronic claim submission. Reach out to CEDI for further details.

Today managing all these for DME providers while ensuring accurate billing practices at the same time can be really confusing and overwhelming. But these are necessary for proper reimbursement and compliance with Medicare regulations. Here are a few essential DME billing tips to keep in mind:

Medicare Billing Considerations for Healthcare Providers

  • Patient eligibility verification – Before providing the DME, verify the patient’s Medicare eligibility to ensure active coverage and eligibility for reimbursement.
  • Ensure that the DME product falls under covered equipment or services – While Medicare covers a broad spectrum of medical services, ensure that the services/equipment you provide are eligible for reimbursement to avoid claim denials.
  • Coding and documentation – Precise coding and detailed documentation of services are essential for accurate reimbursement. Proper coding accurately describes the services, while thorough documentation supports medical necessity. Also, advance beneficiary notice (ABN) is important in DME billing. When Medicare is likely to deny payment for a service, provide the patient with an ABN, informing them of potential responsibility for payment.
  • Timely filing – Adhere to Medicare’s specific filing timeframes to avoid claim rejection due to untimely submission.
  • Billing errors and audits – Vigilance against billing errors is vital to prevent penalties or payment recoupment. Medicare conducts audits to verify the accuracy of claims submitted.

Outsourcing and Partnering for Success

The complexities associated with Medicare billing necessitate expertise and precision in current times. Partnering with professional medical billing companies specializing in handling Medicare claims like Sunknowledge can be a lifesaver. In fact, outsourcing your DME billing to an experienced RCM solution provider like us offers several benefits.

By streamlining the claims process and ensuring a faster turnaround time, our experts reduce the rate of denials noticeably. Being well-versed in Medicare regulations and guidelines, we further decrease the risk of compliance related issues. Offering end-to-end solutions – from patient eligibility verification to claims submission and following up on the payment – at a cost effective rate and without compromising on the billing standard or productivity, partnering with us frees up your resources to focus on patient care instead of navigating complex billing procedures.

If you are looking to wave your DME billing worries away, contact us today.