DME Billing Services: Maximize Payment, Minimize Denials

DME billing is a big part of medical billing and coding. HCPCS Level II codes capture non-physician services, supplies and durable medical equipment. MedCare MSO’s certified DME billing specialists know the unique coding requirements of DME. Partner with us to get paid more, increase patient satisfaction and focus on what matters most patient care.

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Outsourcing Medical Billing for an Efficient DME Billing Process

1. Complex Coding:

CMS updates HCPCS Level II codes for DME in medical billing every year medical billers need to update codes These complexities can impact claims big time and requires attention to detail.

HCPCS Level II Codes: DME claims rely heavily on Healthcare Common Procedure Coding System (HCPCS) Level II codes. These codes are alphanumeric and are used to identify products, supplies and services not covered by CPT codes.
Specific codes for specific items: Each piece of DME has a specific HCPCS code to categorize its use, type and medical necessity. For example, a semi-electric hospital bed with head and foot adjustment uses code E0260 while a CPAP machine is coded E0601.
Different codes for renting or purchasing: DME billing allows for both renting and owning equipment and specific codes are designated to distinguish between the two.
Modifiers: Modifiers are important in DME billing and provides additional information about the item and its use. Modifiers can indicate factors such as rental periods (e.g. first month rental), medical necessity or extended use. Incorrect use or omission of modifiers can lead to claim denials.

2. Documentation complexities

Accurate documentation is the foundation of DME billing compliance. This includes:

Detailed physician orders: also known as a Standard Written Order (SWO) or Detailed Written Order (DWO), is a document that confirms what a physician has prescribed for a patient. Must be signed, dated, specify the exact DME, patient’s diagnosis, patient information, physician information, length of need and any special instruction. For DME drugs under the DME benefit the order must also specify: drug name, dosage/concentration, duration, quantity and refills.

The detailed physician order acts as a bridge between the physician’s prescription and the DME supplier’s billing process, so the right equipment gets to the right patient and the claim is properly supported for reimbursement.

3. Prior Authorization

Streamlined prior authorization (PA) in Durable Medical Equipment (DME) billing refers to optimizing the process of obtaining approvals from insurance payers before providing DME items to patients.

Time consuming
Complex
Frequent updates
Manual processes
High denial rates

4. Denial Rates

Frequency: 20-30% of DME claims are denied initially, that’s how prevalent errors in documentation and coding are. One industry report says up to 20% of all medical claims are denied on the first submission.
Impact: Denied claims requires costly and time-consuming rework, average cost of rework is $118 per claim for complex DME cases.
Causes: Common reasons for DME claim denials are inaccurate coding, insufficient documentation (missing patient info or prescription), no prior authorization, insurance coverage issues.

Also using outdated coding resources and not meeting specific payer requirements contributes to denials.

5. Delayed Reimbursements

Impact: Delayed reimbursements disrupt the cash flow of DME providers especially smaller practices.
Causes: Failure to get proper prior authorization is a big factor. Long processing time for claims that requires manual intervention also contributes to delays.
Consequences: Besides financial strain, delayed reimbursements can also impact patient care by delaying access to equipment. This can lead to patient frustration and potentially harm the provider’s reputation.

Regulatory Compliance Risks

Incorrect HCPCS codes
Upcoding and down-coding
Unbundling codes
Duplicate billing
Missing or incorrect modifiers
Outdated codes
Consequences of failed audits
Inadequate medical necessity documentation
Missing or incomplete patient records
Failure to maintain proper proof of delivery

Varying payer guidelines
Prior authorization requirements
Anti-Kickback Statute (AKS) and Stark Law violations
False Claims Act violations
Providing faulty or non-compliant equipment
Improper handling of PHI
Insufficient data security
Inadequate business associate agreements
Increased scrutiny from government and private payers

How MedCare MSO Simplify Your DME Billing

Accurate Coding

Certified Coders
Code Selection
Modifier
Diagnosis Code
Stay Current
Review
Address Incompleteness
Specific Requirements
Timely & Consistent Documentation
Payer-Specific
Eligibility
Prior Authorization
Timely Filing
Internal Audits
Staff Training

Benefits of EPA

Faster approvals
Better patient care
Less administrative burden
Less errors and rework
Better communication and transparency
Cost savings
Revenue cycle management
Use ePA solutions
Standardize workflows
Automate and AI
Centralize and dedicate resources
Document better
Communicate better
Monitor metrics

Denial Strategies & Solutions

Use claim tracking system
Review EOBs and ERAs regularly
Track denials
Categorize denials
Denial log
Understand denial reason
Gather all docs
Correct coding errors
Provide missing info
Medical necessity denials
Resubmit claims promptly
Consult coding resources and payer guidelines

Reimbursement and Revenue Cycle Management

Denial analysis
Staff training and education
Denial management software
Payer collaboration
Proactive
KPIs
Understand payer appeal process
Gather all supporting docs
Prepare appeal letter
Appeal first, not resubmit (for incorrect denials)
Submit appeals timely
Follow up with payer
Escalate if necessary (Document everything)

Feel free to reach out to us at 800-640-6409 with any questions or for a free demo to see how Medcare MSO can revolutionize your DME billing process. We look forward to partnering with you!

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DME Billing Services: Maximize Payment, Minimize Denials

Outsourcing Medical Billing for an Efficient DME Billing Process

1. Complex Coding:

2. Documentation complexities

3. Prior Authorization

4. Denial Rates

5. Delayed Reimbursements

Regulatory Compliance Risks

How MedCare MSO Simplify Your DME Billing

Accurate Coding

Benefits of EPA

Denial Strategies & Solutions

Reimbursement and Revenue Cycle Management

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