Durable medical equipment has become a very challenging and complicated billing process.
To correctly submit claims to the payer, the medical biller must be familiar with purchases, rentals, recurring, and repair billing, along with unique modifiers reflecting these types of supplies. In addition to these challenges, there are policies for medical necessity, limited/maximum benefits, and exceptions for nursing home and hospitalization settings. Additionally, Medicare beneficiaries are choosing Medicare Advantage plans more frequently, impacting billing. Express Medical Billing understands how to track and manage all of these billing challenges. We have developed custom programming to track your rentals and recurring items, manage your AR and still turn over your receivable efficiently.
Express Medical Billing, Inc. has experience billing competitive bidding supplies and the specific modifiers that are necessary.
Each of the following equipment and/or supply is included in the Competitive Bidding Program.
• Commode Chairs
• Continuous Positive Airway Pressure (CPAP) devices and related supplies
• Diabetes testing supplies (mail-order only)
• Enteral nutrient equipment and supplies
• Hospital beds and related accessories
• Nebulizers (standard) and related supplies
• Negative Pressure Wound Therapy (NPWT) pumps and related supplies
• Oxygen and related equipment and supplies
• Patient lifts
• Respiratory assist devices (RADs) and related supplies
• Scooter and related accessories
• Seat lifts
• Support surfaces (group 1 and group 2)
• Transcutaneous Electrical Nerve Stimulation (TENS) devices
• Walkers
• Wheelchairs (manual, power, and complex) and related accessories
Nebulizers
New prescriptions are required each time a nebulizer is purchased or rented to administer the prescription. If the prescription changes in any way, a new prescription is then required. If an item is replaced, there is a change in the supplier, if the state has specific requirements stating as such, or if LCD policy requires, a new prescription must be obtained.
Also, per Noridian’s LCD policy, the information supplied for frequency of use must include detailed instructions for use as well as the specific amounts to be distributed. Terms such as “PRN” or “as needed” are not considered reimbursable or specific enough to be medically necessary. As outlined in the policy, supply of a nebulizer, including the medication of use noted within the documented order, to be used as a “rescue” medication is considered covered.
As per all DMEPOS, a detailed written order must be filed prior to the claim with Medicare. Requirements for new written orders can be required annually but vary by region.
Nebulizers are considered capped rental items. Items are billed to insurance and once the allowed number of months has been paid, the item is then considered a purchase and the patient owns the equipment.
Oxygen, Portable
The physician must provide a face-to-face examination with the patient before the Written Order Prior to Delivery (WOPD). It must be medically necessary that the portable oxygen will aid in improving the functioning of a malformed body member through oxygen therapy. There are prescription renewal requirements per Medicare LCD policies as well. An in-person exam must take place for any and all new prescriptions or changes to existing prescriptions. The patient’s medical record must supply sufficient documentation of the patient’s medical necessity of the in-home oxygen therapy. The type of oxygen therapy, quantity, and frequency of use must all be documented as well. The physician does not have to complete the WOPD, but they must review, sign and date it.
The billing of stationary and portable systems takes place over a 36 month rental process. There are many documentation requirements throughout. We make it our job to know when skilled-nursing -facility-stays, inpatient-stays or changes in insurance occur to ensure you receive accurate compensation for services provided.
Continuous Positive Airway Pressure (CPAP)
CPAP machines are covered for those diagnosed with obstructive sleep apnea (OSA). CPAP machines are found medically necessary for OSA as it provides air pressure to prevent the collapse of the oropharyngeal walls and obstruction of airflow during sleep that occurs with OSA.
An unattended, in-home sleep study (HST) must be ordered and obtained in order to properly diagnose OSA in the patient. Once the CPAP is ordered, education with the patient and/or caregiver must precede the use of the CPAP. There must be someone in the home who is regularly available to safely operate the CPAP.
Both the apnea hypopnea index (AHI) and the respiratory disturbance index (RDI) must be measured and indicated during the initial 12-week period the CPAP is in use. Generally, the use of a CPAP machine is covered for a 12-week period.
As with nebulizers and other DME supplies, Medicare covers the initial 13 months of the CPAP equipment rental to the supplier. Following the processing of all claims with the patient’s insurance and payment received on all outstanding balances, the patient owns the equipment and supplies.
Manual (MC)
There are several categories wheelchairs. Within the manual category, there are three subcategories. The 2 types of manual wheelchairs are lightweight wheelchairs, high strength lightweight wheelchairs, and heavy duty wheelchairs. Heavy duty/bariatric wheelchairs are used when the patient weighs 250 pounds or has severe spasticity.
There are also wheelchair accessories that are eligible to be billed including but not limited to elevating leg rests and cushions.
The criteria for billing wheelchairs are specific. The patient must have a mobility limitation that prevents the patient from completing daily activities within the home. A patient is eligible for a wheelchair when a cane or walker is no longer sufficiently helping with mobility. The patient’s home must accommodate a wheelchair. A patient is also eligible when it can be argued that having the wheelchair will help the patient’s ability to do every day activities within the home and the patient is willing to try the wheelchair and see if it will help. It is imperative that the patient has the mental and upper body strength to operate safely with a manual wheelchair. Also, the patient must have a caregiver who can assist with the use of the wheelchair.
Powered (PWC)
The requirements for medical necessity to bill powered wheelchairs can be found on CMS. A powered chair can be medically necessary if the patient has limitation of mobility that makes it difficult to accomplish everyday activities within the home, if the use of a cane or walker is not sufficient or safe to help with the patient’s mobility, and/or the patient does not have enough upper body strength to use a manual wheelchair on an average day.
A specific type of powered wheelchair is the complex rehabilitation chair. These chairs fall under the Complex rehabilitation technology (CRT) billing within DME. CRT chairs are the wheelchairs and/or seating systems that are specifically configured to meet the unique needs and capacities for basic activities. These are considered necessary when configured for the purpose of preventing hospitalization or institutionalization of a patient with complex needs.
CRT chairs serve patients primarily for those with illness and/or injury.
Power Operated Vehicle (POV)/Scooter
Outside of wheelchairs, there are also power operated vehicles (POV)/scooter. A patient has to be able to do each of the following actions to be considered for a POV/scooter:
• Safely transfer to and from a POV
• Know how to operate the tiller steering system
• Maintain postural stability and position while operating the POV in the home
• Patient’s mental and physical abilities are able to safely use the POV in the home
• Patient’s weight is less than or equal to the weight capacity of the POV as well as be greater than or equal to 95% of the weight capacity of the next lower weight class of POV
• Patient’s home provides adequate access between rooms, space, and surfaces
• Using a POV can improve the patients everyday activities
• Patient is interested in using item
If a patient does not meet the requirements for a POV, they are likely to be directed towards a powered wheelchair.
Medicare covers each of the following diabetes supplies when medically necessary.
• Blood sugar (glucose) test strips
• Blood sugar testing monitors
• Insulin
• Lancet devices and lancets
• Glucose control solutions
• Therapeutic shoes or inserts
• Orthotics
• Urological supplies
Shoes and Inserts
The prescribed, billing and documentation requirements for reimbursement of supplied diabetic shoes include but are not limited to:
• A diabetes diagnosis
• History of partial or complete foot amputation
• History of previous foot ulceration
• History of pre-ulcerative callus
• Nerve damage due to diabetes and has signs of problems with calluses
• Poor circulation
• Foot deformity
• Patient is being treated under a comprehensive diabetes care plan and needs therapeutic shoes and/or inserts because of diabetes.
Per Medicare policy, when a patient meets the requirements of medically necessity, they are eligible to receive one pair of shoes and 3 pairs of inserts per calendar year. A podiatrist or other qualified physician must prescribe the shoes.
Shoes
The prescribed, billing and documentation requirements for reimbursement of supplied diabetic shoes include but are not limited to:
• A diabetes diagnosis
• History of partial or complete foot amputation
• History of previous foot ulceration
• History of pre-ulcerative callus
• Nerve damage due to diabetes and has signs of problems with calluses
• Poor circulation
• Foot deformity
• Patient is being treated under a comprehensive diabetes care plan and needs therapeutic shoes and/or inserts because of diabetes.
Per Medicare policy, when a patient meets the requirements of medically necessity, they are eligible to receive one pair of shoes and 3 pairs of inserts per calendar year. A podiatrist or other qualified physician must prescribe the shoes.
Inserts
Left and right modifiers are required when submitting custom orthotic inserts. The second insert may bundle unnecessarily but there are modifiers that can be resubmitted on the claim. Inserts and how they bundle vary from insurance to insurance.
Orthotic HPCPS codes related to diabetic supplies are to be reported for the evaluation and fitting of the orthotic. Training time necessary for the patient to use the orthotic is separately billable per 15 minute intervals. Documentation must provide specific support for both codes.
There are multiple orthotic management and training HCPCS codes depending on the initial training and follow-up training for orthotic use.
Orthotic management and training can include:
• Instruction for orthotic wear
• Exercises performed while the patient wears the orthotic
• Skin care instruction during the wear of an orthotic
• Modification of the orthotic due to healing or change of skin/tissues
Leg, arm, back and neck braces are also billable orthotics. Braces service patients who experience weakened body members or have a deformed body part. They can also serve to restrict or eliminate motion in diseased or injured patients when necessary.
Multiple codes can be described for the same item. It is beneficial to be aware of the difference between the off-the-shelf (OTS) HPCPS code and the custom fitting HPCPS code.
Minimal self-adjustments to braces can be made without the required services of a certified orthoptist
Incontinence Supplies
Urological supplies are considered necessary when patient is experiencing decreased bladder or bowel control and/or incontinence. However, Medicare does not cover incontinence supplies. Medicaid may cover them if there is an exception form on file as submitted by the patient’s physician.
The exception form acceptable by Medicaid must contain the HCPCs code. The HCPCs code submitted is determined by the size or type of item. Also to be noted is the number of items allowed per month. Once approved, the supplies are billable for up to a full year.
The HCPCs code range from T4521-T4544 and each code denote the age of the patient, type of supply, size of the supply, and whether or not it is disposable or reusable.
Urinary Catheters
Medicare will cover urinary catheter and other urinary collection devices when a patient has a diagnosis of permanent incontinence.
Indwelling catheters are considered primary to urinary catheters and urinary collections devices when being reimbursed. Indwelling catheters (urethral or suprapubic catheters) are those that reside within the bladder and can be used for short or long periods of time.
External catheters (condom catheters) are those placed on the outside of the body and are typical for men. Depending on the brand supplied, daily change of external catheters may be required.
Short term catheters (intermittent catheters) are used for short periods of time, typically following surgery, until the bladder empties. There are multiple types including rubber, plastic (PV), and silicone. Short term catheters can be used within the patient’s home.
A patient is eligible for up to 2 leg bags and 2 night bags for urinary collection.
Documentation within the WOPD should state whether the patient is stationary, ambulatory or in use of a wheelchair. Coverage of the urinary supplies can depend on these factors.
Commodes
The initial requirement to billing for a medically necessary commode is when the patient in a bed for the majority of their day and/is unsteady to mobilize.
A 3-in-1 commode chair is one that can function as it states, in 3 ways. It can function as a free standing bedside commode. Second it can function as a safe, elevated seat when placed over the toilet itself with a bucket removed. Finally, it can be utilized as a safety frame to use with a conventional toilet when the seat and bucket are removed.
A Standard bedside commode chair: is composed of 3 fixed components, the frame, bucket, and seat. The particular commodes can have four legs and remain stationary for maximum stability or have wheels so it can easily be removed from bedroom to bathroom.
An uplift assist commode features a mechanism to help raise the patient from a seated position to a standing position once finished.
Other optional supplies that can be necessary to provide and bill for in conjunction with commodes are
• Treated plastic, PVC plastic, aluminum, or stainless steel construction
• Folding arms and legs for easy transportation or fixed arms and legs for stability
• Fixed arms, drop arms, or slide-away arms
DME billing also includes billing for hospital beds utilized within the home. Hospital beds serve two major purposes. They offer positioning that is not achievable in a regular bed and allow for use of equipment that cannot be used on a regular bed. Examples of such equipment are a bed-size rail and/or a trapeze bar.
A bed-size rail is a safety device to prevent the patient from rolling out of bed and to help patients with limited mobility.
A trapeze bar is to provide the patient aid when changing position in bed or to get in and out of bed with little help from others.
As with most billing, Medicare has specific requirements for reimbursement.
• The hospital bed must provide change in body positions that is not possible in a normal bed. Of these positions, the body must be able to position in a way that is not possible in a regular bed to relieve pain.
• The head of the bed must be able to reach higher than 30 degrees
• A semi-electric hospital bed is considered medically necessary and covered if the patient requires frequent changes in body position and/or has a need for immediate changes in body position.
• A heavy-duty extra-wide hospital bed is considered medically necessary and covered if the patient weighs more than 350 pounds but does not exceed 600 pounds.
• An extra heavy-duty hospital bed is considered medically necessary and covered if the patient’s weight exceeds 600 pounds.
Items sold, prescribed, and/or needed on a patient to patient basis to correspond with the use of an in-home bed are as follows:
• Bed rails
• Fitted sheets
• Protective bed pads
• Foam wedge
• Trapeze bar
• Mattress overlay