5 Tips on How to Bill Medicare for DME Supplies
- Show Proof of “Reasonable and Necessary” Supplies. Every document you submit with a claim needs to show medical necessity. ...
- Review Documents to Ensure Legibility. All documents must be legible, whether you’re submitting an electronic or paper claim. ...
- Be Clear and Concise. ...
- Use Up-to-Date Codes and Modifiers. ...
- Submit Claim Documents. ...
Full Answer
What DME does Medicare pay for?
· 5 Tips on How to Bill Medicare for DME Supplies #1 Show Proof of “Reasonable and Necessary” Supplies. Every document you submit with a claim needs to show medical... #2 Review Documents to Ensure Legibility. All documents must be legible, whether you’re submitting an electronic or... #3 Be Clear and ...
What is the process for DME billing?
· Corrections to the 2021 DMEPOS Fee Schedule Amounts. On December 11, 2020, CMS released the 2021 Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) fee schedule amounts. The DMEPOS and Parenteral and Enteral Nutrition (PEN) public use files contain fee schedules for certain items that were adjusted based on ...
What DME does Medicare cover?
Answer: See the Medicare Claims Processing Manual, Chapter 20, Section 50, regarding Medicare’s customary payment policy for replacement of DMEPOS. Except as noted below, Medicare will pay for the replacement of equipment which the beneficiary owns or is purchasing, is oxygen equipment, or is a capped rental item when the equipment / item is ...
Does Medicaid cover DME?
6 Definitions of blue words are on pages 18–19. Note: If your plan leaves Medicare and you’re using medical equipment like oxygen or a wheelchair, call the phone number on your Medicare Advantage Plan card and ask about DME coverage options.
When will Medicare release DMEPOS 2021?
On March 11, 2021, CMS released the 2021 April Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) fee schedule amounts. The DMEPOS public use file contains fee schedules for certain items that were adjusted based on information from the DMEPOS Competitive Bidding Program in accordance with Section 1834 (a) (1) (F) of the Act. CMS identified errors in the fee schedule amounts for some items and has therefore released a revised April DMEPOS fee schedule file on March 30, 2021. The April fee schedule files are effective for claims with dates of service on or after April 1, 2021. The revised fee schedule amounts will be used to pay claims received on or after April 1, 2021. No re-processing of claims will be required as a result of these corrections.
When will CMS reprocess claims?
Claims for these accessories submitted prior to July 1, 2020, with dates of service from January 1, 2020 through June 30, 2020, will need to be reprocessed to ensure that CMS pays the unadjusted fee schedule amounts, as required by section 106 of the Further Consolidated Appropriations Act, 2020.
What is a DMEPOS file?
The DMEPOS public use file contains fee schedules for certain items that were adjusted based on information from the DMEPOS Competitive Bidding Program in accordance with Section 1834 (a) (1) (F) of the Act.
What is the Cares Act?
Section 3712 (a) of the CARES Act extends the current adjusted fee schedule methodology that pays for certain items furnished in rural and non-contiguous non-CBAs based on a 50/50 blend of adjusted and unadjusted fee schedule amounts through December 31, 2020 or through the duration of the PHE , whichever is later. Section 3712 (b) of the Act requires the calculation of new, higher fee schedule amounts for certain items furnished in non-rural contiguous non-CBAs based on a blend of 75 percent of the adjusted fee schedule amount and 25 percent of the unadjusted fee schedule amount for the duration of the PHE.
When does the Cares Act end?
Section 3712 (a) of the CARES Act extends the current adjusted fee schedule methodology that pays for certain items furnished in rural and non-contiguous non-CBAs based on a 50/50 blend of adjusted and unadjusted fee schedule amounts through December 31, 2020 or through the duration of the PHE, whichever is later.
What is TTFT in Medicare?
TTFT is a system consisting of an electromagnetic field generator and transducer arrays and will be covered under the Medicare Part B benefit for durable medical equipment (DME) for items and services furnished on or after September 1, 2019.
When did CMS change the fee schedule?
On June 11, 2018 , CMS announced a change to the way that fee schedule amounts for DME are established, indicating that prices paid by other payers may be used to establish the Medicare fee schedule amounts for new technology items and services.
Can DME be waived?
Answer: No. However, in a particular emergency, specific wa ivers could be granted to permit DME suppliers additional time to comply with medical necessity documentation requirements. But the requirement to submit such documentation cannot be waived altogether.
Does Medicare pay for oxygen equipment?
Medicare does not pay for the replacement of rented equipment (except, as noted above, oxygen equipment or capped rental items). Medicare also does not pay for replacing items that require frequent and substantial servicing.
Does Medicare cover oxygen?
Answer: Yes. Medically necessary oxygen in connection with and as part of the ambulance service would be included in Medicare’s payment to an ambulance supplier when a beneficiary is transported by ambulance and such transport is a Medicare-covered service. In addition, separate payment under Part B can be made to a DME supplier for portable oxygen ...
Why do beneficiaries need a secondary provider?
Due to the limited utilities of phone, power and internet, beneficiaries have sought a secondary provider to support their respiratory needs during the state of emergency. We respectfully request CMS allow the secondary provider to bill for life-sustaining respiratory services rendered to a patient residing in the Hurricane Sandy-affected area.
What are the E0450 and E0463?
Due to the beneficiary’s complex needs, requiring the use of respiratory devices from mechanical ventilators (E0450 & E0463) and Respiratory Assist Devices (RAD), a number of patients have chosen to remain at home without power. To support these life-sustaining devices requires supplemental external batteries to maintain the respiratory devices to continue to function and support the respiratory needs of the patients. Based upon the factors outlined here, we request CMS to allow providers to bill for supplemental batteries to support these devices for patients residing in the Hurricane Sandy-affected area.
What is the CPM code for DME?
The CPM devices (HCPCS code E0935) are classified as items requiring frequent and substantial servicing and are covered as DME as follows (see the Medicare National Coverage Determinations Manual.):
Can a supplier charge for a non-upgraded DMEPOS item?
Suppliers are permitted to furnish upgraded DMEPOS items and to charge the same price to Medicare and the beneficiary that they would charge for a non-upgraded item. This policy allows suppliers to furnish to beneficiaries, at no extra costs to the Medicare program or the beneficiary, a DMEPOS item that exceeds what the non-upgraded item that Medicare considers to be medically necessary. Therefore, even though the beneficiary received an upgraded DMEPOS item, Medicare’s payment and the beneficiary’s coinsurance would be based on the Medicare allowed amount for a non-upgraded item that does not include features that exceed the beneficiary’s medical needs.
What is PIM in Medicare?
Chapter 5, section 5.2.1 of the Medicare Program Integrity Manual (PIM) states that, in order for Medicare to make payment for an item of Durable Medical Equipment Prosthetic, and Orthotic Supplies (DMEPOS), the DMEPOS supplier must obtain a prescription from the
What is used equipment?
For payment purposes, used equipment is considered routinely purchased equipment and is any equipment that has been purchased or rented by someone before the current purchase transaction. Used equipment also includes equipment that has been used under circumstances where there has been no commercial transaction (e.g., equipment used for trial periods or as a demonstrator).
What is an enteral care kit?
Enteral care kits contain all the necessary supplies for the enteral patient using the syringe, gravity, or pump method of nutrient administration. Parenteral nutrition care kits and their components are considered all-inclusive items necessary to administer therapy during a monthly period.
How is PEN coverage determined?
The PEN coverage is determined by information provided by the treating physician and the PEN supplier. A completed certification of medical necessity (CMN) must accompany and support initial claims for PEN to establish whether coverage criteria are met and to ensure that the PEN therapy provided is consistent with the attending or ordering physician's prescription. DME MACs ensure that the CMN contains pertinent information from the treating physician. Uniform specific medical data facilitate the review and promote consistency in coverage determinations and timelier claims processing.
Do you need to submit additional documentation to a beneficiary?
There must be no requirement for suppliers to submit additional documentation to describe a beneficiary's medical condition and functional abilities when the supplier bills for a higher level of equipment than previously supplied.
What is DME billing?
DME billing is the process of submitting and receiving payment for a claim from the insurance company. Implementing, maintaining, and educating staff on proper billing is vital to a DME provider’s success.
What is a DME billing specialist?
A DME billing specialist’s goal is to ensure all submitted claims are accurate and contain all the required paperwork to reduce the number of rejected claims. They have several responsibilities, including ensuring compliance with payors guidelines, checking and correcting HCPCS codes, submitting and following up on claims, and more.
What is outsourcing DME billing?
Outsourcing DME billing services can provide you access to DME billing specialists. Those specialists can process claims, check on claim status, stay current on all payor guidelines, and more. Outsourcing billing services can free up extra time to be sent on marketing or bringing in new business.
What is Medicare DME audit?
Medicare DME claims audits help to ensure all claims submitted are accurate and correctly paid. If you receive an audit request, make sure you respond by the deadline, send all the requested documents, and begin reviewing the audited claim internally.
Obtaining a Provider Number
If you want to receive reimbursement from a Durable Medical Equipment Regional Carrier (DMERC), then you have to provide your number—your DMEPOS number, that is. Not to be confused with your NPI number, your DMEPOS number is required to receive reimbursement for items like splints, orthotics, and other supplies.
Picking the Right Codes
There are several different codes providers can use to bill for orthotics, prosthetics, and DMEs—and it’s absolutely crucial that you pick the right one.
Obtaining Reimbursement
Now, on to the good stuff: getting paid. There’s a lot at play here, so let’s dissect what, exactly, payers are reimbursing you for during these interventions. (Note: The information below refers to how Medicare reimburses for prosthetics and orthotics and does not necessarily reflect how commercial payers reimburse for these interventions.
Renting or Selling DME
If your patient decides to rent or purchase a DME item, your DMERC will want to know. You can inform your DMERC of the patient’s decision by including one of the following modifiers on the claim:
Proving Medical Necessity
For certain items, the DMERC requires a certificate of medical necessity (CMN). Each DMERC has its own list of items requiring a CMN, but these lists typically include the following items:
Billing for TENS Units
Billing for TENS units is little tricker than billing for other pieces of DME. In fact, it can even be difficult to receive reimbursement for TENS units, with nearly half of all claims for TENS units being denied. The number-one reason for those denials? Incorrect billing procedure.
