DME billing is a bit different when viewed in conjunction with the other genres of medical billing. Durable medical equipment (DME) provides therapeutic benefits to patients suffering from certain medical conditions and/or illnesses. A DME is designed to serve a medical purpose with the ability to withstand regular wear, appropriate for use in the home. Regular DME items include:

  • wheelchair
  • braces
  • slings
  • crutches
  • cranes
  • compression sleeves

Surprisingly, however, despite its importance, DME billing has a lot of uncertainty surrounding it. It is truly unfortunate that even though DME providers get enough medical orders for supplies, they often struggle to recoup expected revenue.

Different DME companies have different styles of DME billing based on frequency. Some companies bill regularly when needed, while others bill a few times during the year. DME billing must be extremely thorough and accurate, as a single billing error for a single medical device can result in a loss of thousands of dollars for a DME vendor.

To work through the gaps in provider/vendor DME billing, we need to understand the DME billing process.

DME Billing Process – A Brief Overview

These are the key components of a typical DME billing process:

Prescription:

The main requirement for the billing of DME is a prescription from the doctor who orders the rental/purchase mentioning the quantity of DME mentioned.

Check:

Verification of demographics and other patient data before submitting claims.

Credentials:

When DME providers bill, they must meet credentialing criteria before claiming reimbursement. Note: Billing from DME providers is sent to the DME provider and not to the Medicare Part B provider. However, one exception is covered casting supplies.

Form:

The CMS-1500 is the designated form for processing an invoice electronically.

Documentation:

Completion of documentation with the physician’s treatment plan, along with the time frame for DME use, should be ensured.

Codes and modifiers:

It is very important to apply the appropriate HCPCS codes, procedure codes, maintenance and repair modifier codes. In the absence of a qualifying code, E1399 or other HCPCS codes may be used. Note: A denial may occur if HCPCS is used before the shelf life of the product expires (usually 1-3 years).

Factory invoice:

A physical invoice (not sent electronically) containing the full description of the item must be attached along with the medical necessity form signed by the physician. Note: All initial documents must be enclosed in an envelope and then submitted. Before this, the electronic processing cannot be started.

Dates:

The date of injury (DOI) must be clearly stated. If necessary, list the Date of Service (DOS), which is the day the patient died or the day the DME was discontinued. Note: The date of service is the date the patient receives the equipment. Not the shipping date to be precise. The only exception is patient cancellation of the order, where the date of service becomes the date the equipment order is cancelled.

Backup documents:

Attach documents to support the need for the product, such as medical record notes, surgery notes, LMN/CMN, product description, etc.

Coverage:

Coverage begins on the day the device is delivered, configured/installed, and ready for use by the patient in the desired location (usually home) or in a skilled nursing facility.

Claim for repairs:

Bill any repair claim with a full explanation of services.