Durable medical equipment (DME) billing continues to be scrutinized by Medicare and other commercial carriers. The Centers for Medicare and Medicaid Services (CMS) offers extensive and detailed documentation guidelines for DME in general, as well as other guidelines for documentation that can be found in Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs).
Everyone needs to understand DME documentation requirements. Podiatrists, orthopedic surgeons, physical and occupational therapists, orthotists and orthotic technicians, administrators and office managers, coders, billers, transcriptions, and scribes: Without understanding and following documentation requirements, you’re putting your office at risk to fail an audit.
Not only that, but you face refunding an insurance carrier or CMS, which would be an unfortunate and unnecessary revenue loss for your practice. It’s important to learn about the complicated documentation requirements for DME from a general rules perspective as well as what is needed for specific kinds of DME, notes coding expert Lynn M. Anderanin in an audio conference for ProfEdOnDemand, “CMS 2018 Documentation Guidelines for DME.”
The lengthy documentation process for DMEs includes a paper trail that heavily supports medical necessity of the DME. For DME supplies that require prior approval, a provider prescription and clinical documentation are necessary and must support this requirement.
Not sure if the item in question requires prior authorization? Check out CMS’s Durable Medical Equipment, Prosthetics/Orthotics, and Supplies Fee Schedule.
Medicare requires a prescription before approving payment for any DME. This prescription may originate with a physical therapist starting the documentation process and an approved physician providing the prescription. Communication is key, as the script and supporting documentation need to prove medical necessity. In doing so, the following information is required:
- Licensed provider’s plan of treatment
- Anticipated benefit and outcomes from using the DME
- Detailed member’s clinical and functional status so that a determination of medical necessity can be made
- Patient’s medical record
Avoid Insufficient Documentation Errors
If any condition of payment is missing, including just one physician signature, your claim is at risk to fall into the Insufficient Documentation Error category, which has the potential to prolong payment or cause a denial.
Beware: Your claim could fall in this error category if the reviewer couldn’t conclude that some of the allowed services were actually provided, were provided at the level billed, or were medically necessary.
The Medicare Learning Network’s “Complying With Medical Record Documentation Requirements” outlines Insufficient Documentation Errors for DME; here’s how to avoid them:
- Check which DME Healthcare Common Procedure Coding System (HCPCS) codes (e.g., hospital beds, glucose monitors, and manual wheelchairs) require a valid detailed written order prior to delivery according to MLN Matters® Article MM8304.
- Make certain the physician’s National Provider Identifier (NPI) is on the valid detailed written order.
- Know that Medicare will pay claims for DME only if the ordering physician and DME supplier are actively enrolled in Medicare on the date of service.
- As a condition for payment, be sure that a physician, Physician Assistant (PA), Nurse Practitioner (NP), or Certified Nurse Specialist (CNS) documents a face-to-face encounter examination with a beneficiary in the 6 months prior to the written order for certain items of DME.
The devil is in the details when dealing with payment denials, so you need to get up to speed on:
- Using the right modifiers to confirm you have the proper documentation needed for reimbursement;
- Understanding the latest policies from major insurance carriers on pre-authorization requirements;
- Knowing what proof of delivery rules you should be following; and
- Comprehending advanced beneficiary notices for Medicare and commercial insurance carriers.
DME presents a particular challenge when it comes to payment. Because DME items are not professional services, Anderanin explains, your practice is purchasing the equipment in hopes that you will receive a profit in return. If you are audited and don’t have proper documentation, your organization will have to give that money back—and possibly be penalized. So it’s time to get your DME documentation ducks in a row!