A Step-by-Step DME Billing Guide To Get Paid

Running a seamless Durable Medical Equipment billing operation is not as easy as it may seem. DME billing, in fact, stands apart from other medical billing and coding specialties, requiring specialized training due to the diverse range of medical situations and equipment involved. Unlike traditional coders and billers, a DME specialist must navigate various modifiers and possess an in-depth understanding of a wide array of HCPCS Level 2 codes in order to institute an improved DME billing process.

Let us now delve into coding procedures that enhance the efficiency of the billing process.

DME billing stands apart from traditional medical billing and coding due to its requirement for a deeper understanding of various medical scenarios and specialized Durable Medical Equipment (DME) items. Unlike standard medical billing which primarily employs HCPCS Level I codes, DME billing utilizes a range of HCPCS Level II codes tailored to specific equipment.

Moreover, modifiers play a crucial role in DME billing, influencing the approval or denial of claims, whereas in other kinds of medical billing, modifiers are often optional and have limited impact on claim approval. The reimbursement process in medical billing is notably complex and lengthy, with even minor errors potentially leading to claim denial. On contrast, medical billing reimbursement is typically linked to revenue or procedure codes.

Furthermore, HME billing involves distinct coding and requirements regarding equipment rental or ownership, with codes specifically designated for items rather than procedures, unlike general medical billing which primarily focuses on coding for services or procedures rendered.

Here is a comprehensive guide with practical advice for seamless transactions for a DME billing company:

  • The first and foremost step to initiate HME billing is to gather all necessary paperwork for the DME product being billed for (such as crutches, walkers, canes, commode chairs, CPAP machines etc.) Gathering all the information (prescriptions, Certificates of Medical Necessity, prior authorizations, Proof of Delivery etc.) and getting all the other paperwork done correctly help in accurate claims filling and management. Accurate coding and documentation are not only vital for precise claim submission but it can save time and effort in reworking, especially if insurance policies have undergone changes.
  • It is imperative to confirm the patient’s insurance eligibility by contacting the insurance provider and validating the provided details. If the patient’s insurance covers the required DME, it is a very important fact to consider.
  • Establishing medical necessity for the need of the DME product is paramount. The prescribed DME must demonstrate a clear clinical or therapeutic benefit for the patient and must align with the diagnosed medical condition.
  • Once all necessary documentation and data have been collected and verified, the DME provider can proceed to prepare the invoice. Each piece of equipment provided to the patient should be appropriately coded according to HCPCS Level II codes and modifiers. This includes coding not only for the main device but also for any accompanying accessories and supplies.
  • Submitting claims for Medicare reimbursement must be done online, while DME providers meeting specific criteria can opt for filling out and filing CMS-1500, the standard paper claim document used by physicians. Claims submitted to Medicare are evaluated by a Medicare Administrative Contractor (MAC), with processing taking approximately 30 days.

Private insurance companies also accept and process electronic claims. DME providers can submit claims directly through the insurance company’s website or via a clearinghouse, which examines and standardizes the claims format for submission.

To learn more about DME billing, you can also refer to:

Understanding the fundamentals of DME billing

DME billing, prior authorization, limitation and other coverage

Turning your DME billing denial into dollars

Tips to manage DME billing denials efficiently

Demystifying Medicare: DME Coverage Essentials and Basic DME Billing Tips

Working for more than 19 years, Sunknowledge offers specialized DME billing services tailored to meet your unique needs. With a team of experienced billers and DME coders you can easily minimize your Days Sales Outstanding (DSO) and enhance your claim approval rates in no time.

Reach out to us today to discover how we can assist you further!