Inside Secrets To DME Billing

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Inside Secrets To DME Billing
By Anthony Poggio, DPM

What About Coverage Criteria For Diabetic Shoes?

   Diabetic shoes are commonly dispensed DME items from podiatric offices. These are covered per calendar year. Patients who qualify may get one custom shoe with two additional inserts per calendar year or one extra-depth shoe with three additional inserts.

   One may substitute an insole for other accommodations such as rocker sole, metatarsal bar, heel wedges and Velcro closure to name a few. A podiatrist may prescribe and furnish these shoes but the MD or DO responsible for treating the patient’s diabetes must certify the need (i.e., file a CMN) for them.

   Coverage criteria include: neuropathy with evidence of callus formation; history of pre-ulcerative calluses; history of previous ulceration; foot deformity; amputation; and poor circulation. There is no limitation based upon the severity of the diabetes as long as one of the above criteria is met. If the patient is an amputee and only requires one shoe, one should bill for one pair of shoes but only for one insole.

One may use the following codes:

   • Custom shoe: A5501
   • Depth shoe: A5000
   • Prefab insole (not heat molded): A5510/K0628
   • Prefab insole (heat molded): A5509/K0629
   • Custom molded insole: A5511
   • Longitudinal insoles with arch and filler for amputated portion foot: L5000

Understanding The Nuances Of Billing For DME

   Billing for DME providers goes directly to the DME carrier, not to the Medicare Part B carrier. The only “exception” is when you bill for covered cast supplies. This would go to the Part B carrier.

    (When billing Medicare for cast supplies, use the various Q codes. Do not use A4580/A4590. One should bill the Q code as unit “1,” and not per roll as A codes are billed. Also keep in mind that cast supplies are only payable when one employs a cast for a fracture or dislocation. Cast supplies are not payable separately when you use casts for the treatment of sprains, fasciitis, tendonitis or for the use of a total contact cast for ulcers, etc.)

   If you provide both Part B services and DME services on the same date of service (i.e., an office visit, X-ray and a cam walker for an ankle sprain), bill the E/M and X-ray to Medicare Part B and the cam walker on a separate form to the DMERC carrier.

One may use the HCFA-1500 form or ECS to bill claims. The standard patient information one would use to bill Medicare Part B is required.

   • List each item’s HCPCS code and quantity.
   • The date of service is the day you dispense the item, not the day you order the item. You can only collect money from the patient on the day you dispense the item.
   • Be aware that the place of service (POS) is not the office. DME equipment is used in the patient’s home, not in the office. Therefore, the allowable sites of service are home (12) and custodial care facility (33). Other allowable POS include hospice (34), ICF/mental retardation facility (54), residential substance abuse treatment facility (55) and psychiatric residential treatment centers (56). Non-covered locations are office (11), skilled nursing facility (31) and nursing home (32).

Other Key Points You Should Know

   One does not need to submit a claim form for non-covered items. Use the –GA, -GY and –GZ modifiers just as you would for Medicare Part B claims. To bill for denial, you would send the claim to the DMERC carrier, not the Medicare Part B carrier. Also be aware of the KX modifier, which is appended on to the HCPCS item code to indicate that certain specific coverage criteria have been met and are documented in the chart. An example of this would be diabetic shoes.

   If the patient does not pick up the device because the patient changed his or her mind, does not like it or has died, you may still bill DMERC for the item. Indicate that the patient did not pick up the item. The “date of service” is the date the patient died or said he or she did not want the device or a date that you last tried to contact the patient. You will receive a payment that is based upon the hard cost of the item.

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Anonymoussays: February 2, 2010 at 11:55 am

We know how to bill Medicare for Therapeutic Footwear, but we have private insurance patients also. Normally, we have to use NDC numbers to get paid by private insurance companies, PPOs, HMOs, etc. for Diabetic Supplies. How can we bill them for Diabetic Shoes and Insoles?


Frank P. Suess
Diabetic Support Program

Reply to this comment »
Anonymoussays: March 18, 2010 at 4:48 pm what about pharmacist billing for dme? Is this any different from md's or do's? Reply to this comment »

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