Do you know the difference between durable medical equipment (DME) for lower extremities and home care supplies—especially as defined by Medicare? If not, your practice could be facing a lot of unnecessary denials. Time to brush up on Medicare’s DME classification, payment responsibility rules, and DME HCPCS codes!
As always, it’s key that your documentation shows medical necessity, explains orthopedics coding consultant Lynn Anderanin in her live ProfEdOnDemand audio conference. During her presentation, “Orthopedic DME for the Lower Extremity,” Anderanin present attendees with pointers on how to correctly interpret whether the documentation demonstrates medical necessity—and explains how to discuss with patients who is responsible for paying for DMEs and why.
Not Just Any Supplies: DME Requirements
A DME is equipment medically prescribed by a physician and intended to be used in a patient’s home. To properly bill DME HCPCS codes, you must first have a clear grasp of Medicare’s DME classification. This is easier said than done.
Beware: There are medically necessary supplies Medicare won’t cover. For example, Medicare defines canes and crutches as DMEs since they are durable and qualify as medical equipment. On the other hand, exercise equipment isn’t covered because, although it is (hopefully) durable, it isn’t primarily medical in nature.
DMEs designed specifically for the lower limbs include leg, ankle, knee, and foot braces. To be covered, such a brace must be medically necessary—that is, required to treat or diagnose the injury, illness, or condition—and the patient must have Medicare Part B.
Other common lower extremity DMEs are prostheses. For lower limb prostheses to classify as DMEs and be covered, they must:
- Be eligible for a defined Medicare benefit category.
- Be “reasonable and necessary” for the treatment/diagnosis of an illness or injury to improve a lower limb’s functioning. (Here “reasonable and necessary” essentially means that the prosthesis will help the patient function as desired within a reasonable time frame, and the prosthesis motivates the patient to be ambulatory.)
- Meet any and all other Medicare requirements.
Medicare does not provide an exhaustive list of covered/non-covered DMEs. However, the list provided is extensive enough that you should be able to exercise your best judgment and apply logic to your each situation.
Hint: Every year the Centers for Medicare & Medicaid Services (CMS) updates a list of DME HCPCS codes here. No more need to be confused by lower extremity codes—all this information is found on one spot.
So Who’s Paying?
When it comes to DMEs for the lower extremities, the question of who’s paying is often confusing to patients, physicians, and coders alike. If the DME is covered under the conditions mentioned above, the patient is required to pay the deductible plus 20% of the Medicare-approved amount.
But let’s say there’s a situation where, for whatever reason, the equipment is not covered by Medicare. It could be that the patient wants a brace for leg stability but does not need it to treat or diagnose any condition they have. In that case, the physician would have to inform the patient that the equipment is not covered, have the patient sign an agreement to pay for the equipment, and file the signed document in the patient’s medical file.
Rule of thumb: Whenever possible, all parties should be in agreement beforehand who is responsible for paying for the equipment.
Coders: Last Line of Defense
As a coder, you’re the last link in the chain of billing for certain services. It’s your responsibility to check that the patient is eligible for coverage of the equipment, and if they’re not, to ensure they’ve acknowledged responsibility to pay. Not following the rules could cost you dearly, says Anderanin, making it all the more important to check everything off on your list before submitting claims to Medicare.
