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?
What durable medical equipment does Medicare cover? Medicare covers a range of items, supplies and equipment such as durable medical equipment. The list of DME that is covered by Medicare includes (but is not limited to): Air-fluidized beds and various other support surfaces Blood pressure monitors Blood sugar monitors Blood sugar test strips Canes
What is the process for DME billing?
- Patient Check-in and Check-out. Patient check-in and check-out are relatively straight-forward front-of-house procedures. ...
- Prepare Claims/Check Compliance. ...
- Transmit Claims. ...
- Monitor Adjudication. ...
- Generate patient statements. ...
- Follow up on patient payments and handle collections. ...
What DME does Medicare cover?
Medicare may help pay for your manual wheelchair if all of the following conditions are met:
- Your health makes it hard to move around in your home. ...
- You can safely use the wheelchair yourself, or you always have someone with you to help you use it.
- Your doctor signs a written order for the equipment. ...
- You get equipment from a Medicare-approved supplier.
Does Medicaid cover DME?
“Medicare does not currently pay for over-the-counter ... As of Jan. 15, people with private health insurance have been eligible for coverage of up to eight at-home tests per month, per person ...
What is the CPT code for DME?
HCPCS code E1399 describes “durable medical equipment, miscellaneous” and is currently being used to bill for inexpensive DME subject to the rules of 42 C.F.R. 414.220, other covered DME subject to the rules of 42 C.F.R.
What is the purchase modifier for DME?
UEUE — USED DURABLE MEDICAL EQUIPMENT PURCHASE. This modifier is used for used DME items that are purchased. When using the UE modifier, you are indicating you have furnished the beneficiary with a used piece of equipment.
How does Medicare price DME?
Generally, you pay 20% of the Medicare-approved amount after you pay your Part B deductible for the year. Medicare pays the other 80%. The Medicare-approved amount is the lower of the actual charge for the item or the fee Medicare sets for the item.
What is a Medicare DME claim?
covers. medically necessary. Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine. DME if your doctor prescribes it for use in your home.
What is KX modifier for DME?
The KX modifier represents the presence of required documentation is on file to support the medical necessity of the item.
Does DME require a modifier?
In addition to an appropriate HCPCS code for the DME item, many HCPCS codes require a modifier. The modifiers are used to provide more information about the item.
What is the CMS fee schedule?
A fee schedule is a complete listing of fees used by Medicare to pay doctors or other providers/suppliers. This comprehensive listing of fee maximums is used to reimburse a physician and/or other providers on a fee-for-service basis.
What is the noridian fee schedule?
A fee schedule is a complete listing of fees used by Medicare to pay suppliers. This comprehensive listing of fee maximums is used to reimburse a supplier for an item or service. To access the most current fee schedules, select the appropriate Noridian or CMS link(s) below.
What does NR mean on Medicare DME fee?
California Non-RuralIn the 2016 changes to the Official Medical Fee Schedule (OMFS), the California DWC introduces two new columns to the DME file: CA (NR) and CA (R). CA(NR) stands for California Non-Rural. CA(R) stands for California Rural.
How do you write a prescription for DME?
Standardized DMEPOS Written Order/PrescriptionBeneficiary name or Medicare Beneficiary Identifier (MBI) Number.Description of the item.Quantity, if applicable.Treating practitioner name or National Provider Identifier (NPI)Date of the order.Treating practitioner signature.
What is modifier RR?
Hence when DME is a rental, the modifier RR is used for enhancing billing and collections. It comes under the Level II HCPCS modifiers which consist of two digits beginning from AA through VP and usually comprise alpha/alphanumeric characters. This modifier must be used on all claim forms for rental DME.
What is required when billing Medicare for repair of previously purchased equipment?
With respect to Medicare reimbursement for the repair, there are two documentation requirements: Treating physician/practitioner must document that the item being repaired continues to be reasonable and necessary. Treating physician or supplier must document that the repair itself is reasonable and necessary.
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.
When will Medicare change the KU modifier?
As aforementioned, these system changes will be implemented on July 1, 2020.
What is Medicare Accessibility Act?
CMS is implementing the Patient Access and Medicare Protection Act to ensure that beneficiaries have access to wheelchair accessories and seat and back cushions when furnished with Group 3 complex rehabilitative power wheelchairs. To ensure beneficiary access to these accessories particularly for these vulnerable populations, advance payment may be available for suppliers. Prior to July 1, suppliers will be paid the adjusted fee schedule rates. The average reduction during this period for these items is approximately 10%. During this time, CMS has announced that suppliers are able to submit a single advance payment request for multiple claims if the conditions described in CMS regulations at 42 CFR Section 421.214 are met. Additional information is below.
What is gap filling in Medicare?
For newly covered items of DMEPOS paid on a fee schedule basis where a Medicare fee does not exist , the Centers for Medicare & Medicaid Services (CMS) uses a process to establish fees called gap-filling. This allows Medicare to establish a price that aligns with the statutory requirements for the DMEPOS fee schedule.
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 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.
What is a CGM?
CGMs are items of durable medical equipment (DME) that provide critical information on blood glucose levels to help patients with diabetes manage their disease . In January 2017, CMS issued a ruling providing for Medicare coverage of therapeutic CGMs.
What is a DME billing company?
A DME billing company, like Medbill, can become an extension of your billing department and can provide you with numerous services from A/R to audit assistance to revenue cycle management.
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.
Does DME change?
DME payor medical policies often change across the various product lines. Make sure to have a system in place to stay current on all changes before submitting a claim. Regularly checking the CMS’s website is an efficient way to keep up to date on all Medicare and Medicaid DME guidelines.
What is DME in Medicare?
Millions of Medicare beneficiaries in the US rely on durable medical equipment (DME) which includes canes, nebulizers, blood sugar monitors, and other medically necessary supplies. These DMEs are expensive hence physicians should aware of billing for Orthotics and DME as lower reimbursements negatively impacted your revenue cycle management.
Why are DMEs important?
DMEs are necessary to improve quality of life and maintain the independence of patients at home however, due to dynamic regulatory compliances billing of orthotics and DME are renovating. It is observed that DME accounts for only 2% of total healthcare costs in the United States, however, these supplies are important in preventing injuries ...
What is Medicare reimbursement for orthotics?
For orthotics, Medicare reimbursement includes: evaluation, measurement and/or fitting, fabrication and customization, materials, cost of labor, and. Delivery.
Does DME require a prescription?
DME requires a prescription to rent or purchase, as applicable, before it is eligible for coverage. Bill on a typed CMS-1500 (version 08/05) claim form. After all HCPCS codes, bill the applicable modifier (including, but not limited to NU, RR, etc). After the procedure code bill maintenance and repair modifier codes.
Does Medicare cover DME?
During a short-term stay at a skilled nursing facility or hospital, Medicare does not cover DME. However, it only pays for the basic level of DME products available for any given condition.
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.):
How long do DME MACs pay rental fees?
For these items of DME, A/B MACs (HHH) and DME MACs pay the fee schedule amounts on a monthly rental basis not to exceed a period of continuous use of 15 months. In the tenth month of rental, the beneficiary is given a purchase option (see §30.5.2). If the purchase option is exercised, A/B MACs (HHH) and DME MACs continue to pay rental fees not to exceed a period of continuous use of 13 months and ownership of the equipment passes to the beneficiary. If the purchase option is not exercised, A/B MACs (HHH) and DME MACs continue to pay rental fees until the 15 month cap is reached and ownership of the equipment remains with the supplier (see §30.5.4). In the case of electric wheelchairs only, the beneficiary must be given a purchase option at the time the equipment is first provided (see §30.5.3).
How to determine liability to a provider other than an HHA?
To determine patient liability to a provider other than an HHA (including nominal charge providers other than a HHA), A/B MACs (A) subtract any unmet deductible from the actual charge and multiply the remainder by 20 percent. The result, plus the unmet deductible is the patient's liability. Coinsurance is applied as applicable.
How to determine Part B payment to nominal charge?
To determine the Part B payment to a nominal charge HHA , A/B MACs (HHH) subtract any unmet Part B deductible from the fee schedule amount and multiply the remainder by
How to determine Part B payment?
To determine the Part B payment to a provider other than nominal charge provider, A/B MACs (A) and (HHH) subtract any unmet Part B deductible from the lower of the actual charge or the fee schedule amount for the item or service and multiply the remainder by
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.
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.
What is assignment in Medicare?
Assignment —An agreement by your doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance.
Does Medicare pay for DME repairs?
Medicare will pay 80% of the Medicare-approved amount (up to the cost of replacing the item) for repairs. You pay the other 20%. Your costs may be higher if the supplier doesn’t accept assignment.
Where to submit CMS-855S?
To do so, you’ll need to fill out and submit a CMS-855S form (along with all of your supporting documents) to Palmetto GBA, the national supplier clearinghouse for Medicare. If you have questions, you can contact the clearinghouse at 866-238-9652 or visit the Palmetto GBA website.
What are the codes for tens?
You can then bill your DMERC for the two-month rental period as well as the actual purchase. For TENS, the HCPCS codes are E0720 and E0730. For TENS supplies, the codes are A4557, A4595, and E0731. When buying a new pair of jeans, there isn’t much to it outside of picking the right fit. But when it comes to orthotics and prosthetics, ...
Is DME cut and dried?
Unfortunately, purchasing things such as splints, prosthetics, and durable medical equipment (DME) isn’t so cut and dried. In fact, when it comes to orthotics and prosthetics billing, there’s a lot of room for error. Prev.
