How To Bill DME Claims To Medicare: A Comprehensive Guide

Introduction

Medicare plays a crucial role in providing coverage for Durable Medical Equipment (DME) to millions of beneficiaries. Understanding and following Medicare’s specific guidelines is essential for successful DME billing and reimbursement for claims to medicare.

Medicare DME Coverage Criteria

To bill Medicare for DME, the equipment must meet specific coverage criteria:

• The equipment must be medically necessary
• It must be able to withstand repeated use
• It must have an expected lifetime of at least 3 years
• It must be used for a medical purpose
• It’s generally not useful to a person who isn’t sick or injured
• It’s appropriate for use in the home

Medicare Fee Schedule for DME

Medicare uses a fee schedule to determine reimbursement rates for DME. Key points include:

• Rates are typically updated annually
• Different geographic areas may have different rates
• Some items are subject to competitive bidding prices

Medicare-specific Documentation Requirements

Proper documentation is crucial for Medicare DME billing. Required documents include:

Detailed Written Order (DWO)

• Must be completed before submitting a claim
• Must include: beneficiary’s name, specific item ordered, prescribing practitioner’s NPI, signature and date

Certificate of Medical Necessity (CMN)

• Required for certain DME items
• Must be completed by the treating physician

Proof of Delivery (POD)

• Must be kept on file
• Should include: beneficiary’s name, delivery address, sufficiently detailed description of items, quantity delivered, date of delivery, beneficiary (or designee) signature

Additional Clinical Documentation

May include: physician’s notes, test results, or other relevant medical records

Medicare Billing Codes and Modifiers

Medicare uses HCPCS Level II codes for DME billing. Ensure you’re using the most current codes, as they can change annually.

 Common Medicare Modifiers for DME

• KX: Requirements specified in the medical policy have been met
• GA: Waiver of liability statement on file
• GY: Item or service statutorily excluded or does not meet the definition of any Medicare benefit
• NU: New equipment
• RR: Rental

Prior Authorization Process for Medicare

Some DME items require prior authorization from Medicare before you can bill for them.

The list of items can change, so check the CMS Prior Authorization website https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/DMEPOS/Prior-Authorization-Process-for-Certain-Durable-Medical-Equipment-Prosthetic-Orthotics-Supplies-Items regularly Submitting a Prior Authorization Request

1. Gather all required documentation
2. Submit the request to the appropriate DME MAC
3. Wait for a decision (typically within 10 business days)
4. If approved, include the Unique Tracking Number (UTN) on your claim
5. Medicare DME Competitive Bidding Program

The Competitive Bidding Program affects pricing and supplier eligibility for certain DME items in specific geographic areas.

Key Points:

• Check if the item and area are subject to competitive bidding
• Only contract suppliers can bill Medicare for competitive bid items in competitive bidding areas
• Use the competitive bidding rates: https://www.dmecompetitivebid.com/cbic/cbic.nsf for applicable items and areas

Submitting Claims to Medicare

Medicare DME claims are typically submitted on the CMS-1500 form or its electronic equivalent.

Key Considerations:

• Use the correct Place of Service code (usually 12 for home)
• Include the ordering physician’s NPI
• Ensure all Medicare-specific fields are completed accurately

Medicare Payment Policies for DME

Assignment vs. Non-assignment

• Most DME suppliers must accept assignment for Medicare-covered items
• Non-assigned claims may result in higher out-of-pocket costs for beneficiaries

Rental vs. Purchase Guidelines

• Some items are eligible for purchase only
• Others may be rented, with ownership transferring to the beneficiary after a certain number of rental months
• Check the Medicare Claims Processing Manual: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c20.pdf for specific guidelines

Handling Medicare Claim Denials and Appeals

Despite best efforts, some claims may be denied. Understanding the appeals process is crucial.

Common Reasons for Medicare DME Claim Denials

• Insufficient documentation of medical necessity
• Incorrect coding or modifiers
• Missing or incomplete Certificates of Medical Necessity
• Lack of proper prescription or Detailed Written Order

Medicare Appeals Process

1. Redetermination (First Level of Appeal)
2. Reconsideration (Second Level of Appeal)
3. Administrative Law Judge Hearing (Third Level of Appeal)
4. Medicare Appeals Council Review (Fourth Level of Appeal)
5. Judicial Review in Federal District Court (Final Level of Appeal)

Compliance and Audit Considerations

Medicare implements various audit programs to ensure proper payments and detect fraud.

Key Audit Programs:

• Recovery Audit Contractor (RAC) Program
• Comprehensive Error Rate Testing (CERT) Program
• Targeted Probe and Educate (TPE) Program

Tips for Maintaining Medicare Compliance:

• Implement a robust compliance program
• Conduct regular internal audits
• Provide ongoing staff training on Medicare requirements
• Stay updated on Medicare policy changes and transmittals

Best Practices for Medicare DME Billing

To improve accuracy, efficiency, and compliance in Medicare DME billing:

1. Implement a checklist system for documentation requirements
2. Use billing software with built-in Medicare claim scrubbing
3. Regularly train staff on Medicare policies and updates
4. Develop a quality assurance process to review claims before submission
5. Monitor claim denial trends and address root causes
6. Maintain open lines of communication with ordering physicians
7. Regularly review and update your charge master with current Medicare fees

How WWS Can Help with Medicare DME Billing

At Worldwide Solutions Health Care Services (WWS), we specialize in navigating the complexities of Medicare DME billing. Our team of experts can help you optimize your billing process, reduce denials, and ensure compliance with Medicare regulations.

Our Medicare DME Billing Services Include:

• Comprehensive Medicare billing process assessment
• Staff training on Medicare-specific requirements and best practices
• Implementation of Medicare-compliant documentation systems
• Assistance with Medicare audit preparation and response
• Ongoing monitoring of Medicare policy changes and updates

Take the Next Step

Ready to optimize your Medicare DME billing process? Schedule a Collaborative Discovery Meeting with WWS today. We’ll discuss your specific challenges and how our Medicare billing expertise can benefit your organization.

Schedule Your WWS Collaborative Discovery Meeting: https://calendly.com/wwshcs/wws-collaborative-discovery-meeting

Don’t let the complexities of Medicare DME billing hold your organization back. Let WWS help you master Medicare billing and maximize your reimbursement.