A Practical DME Billing Documentation Checklist for Accurate Claims

DME suppliers greatly depend upon accurate documentation in order to support claims, receive timely payment and demonstrate coverage eligibility. In fact, documentation plays such an important role that even if durable medical equipment like a hospital bed or an oxygen concentrator might be medically feasible, the claim can be rejected if the details are not complete.

Incorrect documentation can break down the DME billing ecosystem as it creates informational gaps. These gaps are dangerous since they do not come to the surface easily. As a result, they are often noticed quite late and in that process the billing team ends up doing additional work. If you are facing a similar issue, then follow along and see how professional DME billers can help your practice strengthen its documentation process.

Why Documentation Matters for DMEPOS Claims

Documentation is one of the most important pillars of medical RCM. Every practice needs to bolster its documentation in order to receive claims in a smooth fashion. A durable medical equipment practice is no different. Documentation allows practices to chronicle the entire RCM journey of a claim right from the first visit to the final payment posting.

For a claim to become payable, tracing this journey without any roadblocks is quite important. In other words, a payer can outright deny a claim if the documentation is incomplete. The payer expects the claim to contain every little detail like the previous order detail for a repeating order, the alternative to current equipment prescribed, medical necessity requirements, etc.

This is why DME billing teams must fulfill these documentation requirements as mandated by CMS in their DMEPOS general documentation guidance. In fact, the experienced biller does not just check the federal regulatory bodies, but also the Local Coverage Determination in order to cover as much ground as possible.

Related Reading: DME Billing: Medicare Standard Written Order Rules

Verify the Standard Written Order

The first starting point for a DME biller is the SWO, or Standard Written Order. This is a crucial inception point for DMEPOS claims under the Medicare regulations. Before the billing, the supplier needs to check a bunch of details in order to ascertain that the equipment is supplied under credible circumstances. Here is a more in-depth look at details that providers need to check before the billing goes underway.

Elements to Review

A general SWO primarily includes details such as the name of the beneficiary or the Medicare Beneficiary Identifier, along with other details such as the order date, description of the equipment, applied quantity, the name of the practitioner, and the signature of the same.

Furthermore, the item description might be called general, but it should include a narrative description of the equipment and its use case. Subsequently, the documentation must also include the code and its narrative. Accessories also need separate billing logic and must come with all the necessary details.

Once the equipment is assigned and billed, the final stage is comparing the order with the item that has been billed and dispensed. Every detail such as the product type, quantity applied, coding, etc., is checked minutely. In fact, experienced billers also tend to check if the practitioner is even authorized to assign equipment. These might sound obsessive but are very important as they determine the overall payout.

Check Order Timing

Just as the product details are necessary, so is the order timing. The claim needs to reflect accurate timing of the order, and this should be consistent across the RCM journey. For items that require face-to-face encounters, details about that meeting are also necessary.

The biggest challenge that a biller might face is that not every detail applies to equipment in a uniform fashion. Therefore, the DME billing partner or expert needs to be careful and must refer to the guidelines set forth by CMS.

Confirm Medical Necessity

Once the equipment detail is dealt with, the team can shift its focus towards medical necessity. In the case of DME claims, a simple prescription is not enough for the payer to ascertain that a product is qualified under the criteria. The team must go deeper and look at different components as follows.

What the Clinical Record Should Demonstrate

The answer to this question is very much dependent on the type of equipment, policy regulations, diagnosis, progress report for something that is chronic, response to previous intervention, functional limitation the equipment is solving, etc. Therefore, a simple prescription only stating that equipment is required is never enough.

Payers consider records that come from registered medical practitioners, hospitals, skilled nursing facilities, home health agencies, or other registered providers. Unlike before, a supplier-generated statement or a general letter of requirement is not what the payer wants or entertains.

This is why DME billing experts urge providers to check every detail in order to pinpoint informational aberrations. These tend to derail the entire billing operation and turn payable claims into an A/R nightmare.

Validate Proof of Delivery

Once the equipment is delivered, the final component that a provider needs to assess is the proof of delivery, or POD. This simple documentation allows providers to establish a clear relation between the claim and the billed equipment. It also highlights that the equipment has reached the correct beneficiary. Here is a look at some of the common formats of PODs that DME providers tackle:

Direct delivery and shipped order – For this format of delivery, the record must contain details regarding the name of the beneficiary, delivery address, item description, delivery date, assigned units, and the signature of the permitted beneficiary. Also, for a shipped order, documentation must include details such as the supplier invoice, tracking detail, and detailed information about the relationship between the assigned equipment and the beneficiary’s necessity.

Delivery to nursing facilities – In this case, the file should include a delivery record and documentation from the facility that shows the receipt of the equipment for the beneficiary’s use, along with the supported quantity that has been billed.

Use a Pre DEM Billing Documentation Checklist

DME billing can be a taxing job, to say the least. Therefore, it is common for professional billers to spare some extra minutes in order to determine that the claim is well-documented and follows the mandated workflow. To be sure, billers tend to follow a brisk checklist to assess a bunch of crucial details, such as:

• The beneficiary’s identity and insurance information are correct.
• A valid order is on file, with all required elements and dates.
• The order was received within the required timeframe, including before delivery when WOPD applies.
• Clinical records are in place to establish the medical necessity of the equipment.
• Mandatory documents regarding the face-to-face meeting, performed tests, authorization documentation, and other policy-specific records are on file.
• A detailed rundown of the HCPCS codes, the unit used, the description of the item, and the quantity matches the original documentation.
• Any related documentation regarding repeat orders or chronic cases is included.
• The claim is submitted to the correct payer with complete and consistent data.

The entire purpose of this review is to record who checked the claim file and when. In case there is any informational gap, the provider can hold the claim before it passes onto the adjudication stage. In this situation, the team responsible is brought in to make the changes. Therefore, this check not only looks for errors but also assigns responsibility. As a result, it pushes teams to produce a higher quality of work.

Prevent Common Documentation Errors Through Learning

DME billing is a complicated affair. Therefore, the workflow can be transformed into something that is denial resistant, but completely turning it into something airtight is not possible. Denials will happen, and the billing team will have to work extra hours from time to time.

That does not mean that the team should be working on claims in an isolated fashion. Every denial is an opportunity for the team to learn. Therefore, the billing operation must clearly assess and understand what causes denials. This is one of the only ways in which DME billing can become more resilient.

Related Reading: Customized Your DME Billing Solution Only Just $7/hr per FTE

Epilogue: Allowing Professionals to Take Over

Now, you as a provider might think that you know enough about DME billing, and you are ready to take it on. In reality, DME revenue cycle management is not straightforward. A person might think that they are ready but at the same moment, DME RCM discipline can throw you a curveball.

Therefore, the safest and most reliable way to proceed is to bring in professional support. It is time for providers to let professional billing partners like SunKnowledge take over. This is because our billers not only bring expertise, but also the required experience spanning 15+ years. And the best part is that you can get such expert help at a flat fee of just $7 per hour.

Hence, if you need a specialized DME biller who can help you with documentation, then SunKnowledge is the way to go.