Key Medicare Procedure for Correct DME Billing

Managing accurate Medicare procedures in durable medical equipment (DME) billing can be a struggle for your team. Whether your patient has original Medicare or a Medicare Advantage plan, Medicare provides coverage for the durable medical equipment considering the eligibility conditions. The robust set of rules in Medicare plan makes it overwhelming for your staff and billing errors lead to reimbursement delays or revenue loss. Here, we will not only discuss the different scenarios through which you can learn about Medicare procedures applicable for accurate DMEPOS billing but also how to ensure a seamless DME billing operation.

Medicare Procedures for Your DME Billing Team

The following are the areas you must know for effective DME billing.

Question 1: If your beneficiary’s durable medical equipment, orthotic or prosthetic is damaged, destroyed or lost, will Medicare pay for it?
Answer: As per the Medicare Claim Processing manual chapter 20, section 50, there is coverage for certain items. It clearly states that Medicare will pay for the replacement if the beneficiary owns or purchased capped item. Payment for replacement of parenteral or enteral pumps. If the equipment is lost, irreparably damaged, or rendered unusable due to an emergency, Medicare will pay for them.

Unless it is oxygen equipment or capped rental items, Medicare will not pay for the beneficiary. Coverage is not provided for the equipment that needs frequent and substantial servicing. For Oxygen Equipment and Caped Rental Equipment other than Complex Rehabilitative Power Wheelchair, Payment for Replacement of Equipment is made by Beginning a New 36 Month Rent Period for Oxygen Equipment or a New 13 Month Rent Period for Caped Equipment. Payment for replacement of Complex Rehabilitative power wheelchair, K0835 to K0864, can be purchased as a lump sum or as a rental.

Always make sure you use RA modifier for a replacement item. In case of mobilization of the beneficiary from the disaster/emergency area, beneficiary might obtain the replacement item from a Medicare-enrolled supplier located outside that area.

If the beneficiary has been displaced from a federally declared disaster/emergency region that is, or includes, a competitive bid area (CBA) and the replacement item(s) is a competitive bid items, in addition to billing (RA) with the claim annotated (KT) in this circumstance, the beneficiary will be paid for the CB item(s) at the CB rate(s).

For replacement of standard power wheelchairs (K0813-K0831), payment may be made on a flat-rate purchase or rental basis (BWP) for items furnished on (or before) December 31, 2013, to beneficiaries residing in (Round 1) a CBA. Payment may only be made on (BWP) a rental basis (beginning a new (13-month) rental period) for (standard power wheelchairs) furnished outside the nine (9) round 1 CBAs on (December 31, 2013) or for (standard) power wheelchairs furnished in any (post-Dec 31, 2013) area (after December 31, 2013).

Question 2: If a beneficiary is using a stationary oxygen unit at home and needs transportation to another location, can Medicare pay for any portable oxygen?

Answer: Medically necessary oxygen additional to ambulatory services is covered by Medicare. Furthermore, separate payment under Part B can be made to a DME supplier for portable oxygen, if the transport is not covered by Medicare.

Question 3: Does Medicare cover for a surgical mask used to prevent infectious disease?
Answer: No. There is no such coverage under Medicare.

Question 4: Does Medicare cover a generator, used for medical needs?
Answer: A generator is not and cannot be considered as medical equipment, even if it is using to power durable medical equipment. Legally, Medicare is not allowed to provide this service.

Question 5: If a supplier is dispensing portable oxygen tanks to beneficiaries each day due to power cut in the area and their oxygen concentrators do not work without power. Will the supplier get any reimbursement in addition to the fee schedule? As the above-normal amount of oxygen is being dispensed, can payment be higher than the usual monthly oxygen payments? If so, will there be any billing requirements?
Answer: Well in these situations, supplier would not receive any payment. Medicare payment coverage already considers stationary oxygen equipment, stationary oxygen content and portable oxygen content under the fee-schedule of the supplier. Although, a supplier can get add-on amount as payment for dispensing portable oxygen in case of medical necessity.

Question 6: Can people with Medicare, who have been displaced, without access to their usual suppliers, get access to DMEPOS such as wheelchairs and therapeutic shoes?
Answer: Accessibility to telephone can make it easier for the beneficiaries. They can contact 1800-Medicare for more information. Additionally, through the internet they can go to the Medicare website to obtain a directory listing suppliers by geography, proximity and name.

Question 7: Can medical necessity documentation for DMEPOS be ignored in case of emergency?
Answer: Although in emergency cases specific waivers could be granted to permit DME suppliers additional time to comply with documentation requirements, but requirement of such document cannot be waived altogether.

Question 8: Is the summarization of Medicare payment rules regarding oxygen services by CMS possible, especially in case of changes in delivery modalities during an emergency?
Answer: The Medicare monthly payment for oxygen and oxygen equipment includes payment for all the different modalities. Furthermore, it also contains payment of portable oxygen contents. If there is a power cut and suppliers switch patients into a different modality (for e.g. from concentrator to gaseous or liquid stationery or portable equipment), the Medicare payment costs factor into monthly payments. Hence, there are no additional charges for switching the modalities.

Wrapping Up

Understanding and implementing Medicare plan within your DME billing services, altogether is a complex task. The intricacies within the coverage rules along with billing and coding requirements make the billing process tedious for your existing staff. Furthermore, accurate billing and coding for DME requires a constant and knowledgeable team who understands the complexities within Medicare coverage. Regarding this, you might consider partnering up with an outsourced RCM organization who has a team of expert medical billers and coders. An expert RCM professional like Sunknowledge Services Inc in fact is always updated regarding the changes within the policies and has a better understanding of coverage intricacies. To ensure financial stability in your practice connect with a team who has the best in the industry practices in billing and coding services.