Inside Secrets To DME Billing

Author(s): 
By Anthony Poggio, DPM

   If you dispense and bill a Medicare beneficiary cash for any covered items and you do not have a DMERC license, you are in violation of Medicare policy. This is true even if the patient agrees to pay for the item. If the patient were to complain to Medicare, you must refund the patient the money he or she paid for the item in full and the patient gets to keep the item. This may also prevent you from getting a DMERC license in the future. If you do not have a DMERC license, send the patient to a DME supplier or another podiatrist who has a DMERC license.

   For non-Medicare carriers, check with each plan in which you participate to see what regulations the insurer may have regarding the dispensing of DME items from your office. Many HMOs require the use of preferred vendors. Also be aware that charging patients for otherwise covered DME items/supplies may put you in jeopardy of violating your HMO contract.

   In addition, check to see what provisions there are for “urgent” situations. Invariably a patient will show up in the office at 4:45 p.m. on a Friday with some trauma that may require dispensing a cam walker. However, the insurance offices may be closed at that time, which would hamper your ability to obtain any authorization. Many companies do not issue retro authorizations or at least make the process very difficult and time consuming. Therefore, one may need to adjust the treatment plan to care for this patient in order to get him or her through the weekend until obtaining a formal authorization for a DME device. This may require the use of an Unna Boot or a formal cast instead of the cam walker. Keep in mind that regardless of the hassles of an authorization process, we still must provide services within the standard of care.

Essential Insights On Chart Documentation

   Be aware of Statistical Analysis DMERC (SADMERC), a department that will tell you the correct HCPCS code to use for a specific item. They may ask you to submit a picture, description, catalog information, etc about the item(s) in question. Do not rely on the manufacturer’s recommendations about which code to use.

   The chart note should obviously support the need for any DME item or supply. There must be an order of sorts in the chart indicating the patient’s name, the description of the item ordered (with HCPCS code) and any additional features that may be added on the item. For rented items, list the length of time the patient will need the item. For supplies, list the item, the quantity, frequency of use and the length of need. This requirement applies when sending a patient out for these items or even if you dispense them yourself. Remember, one can be the physician requesting an item and the supplier of that item.

   When dispensing DME items, there is a specific dispensing form that one must fill out. This form serves as a receipt of sorts that the patient received the device. This form should list the item(s) dispensed, the HCPCS codes billed (but not necessarily the amount billed), an indication that the item fit well and that you went over the proper care and use of the device with the patient. Keep a copy of the form in the chart and give a copy to the patient.

   Some items may require a Certificate of Medical Necessity (CMN), which an MD/DO needs to fill out. Podiatrists and orthopedists cannot fill out this form. For example, this form is required for the MD to certify the patient has diabetes and other coexisting conditions when dispensing and billing for shoes under the diabetic shoe program. (See “What About Coverage Criteria For Diabetic Shoes?” below.)

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.

Comments

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?

Respectfully

Frank P. Suess
Diabetic Support Program

fpsuess@prescriptionsplus.com

what about pharmacist billing for dme? Is this any different from md's or do's?

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