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.

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.
Outsource DME Billing Services
DME Billing Codes

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.

DME Medical Billing Challenges

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.

Specific Documentation

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.
DME Billing Companies

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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