DME billing can be a complex, tedious task, especially if it’s assigned to someone without direct experience. You may find yourself drowning in claims forms submissions and waiting too long to be paid due to filing errors. In some cases, you may not get paid at all. 

To avoid the pain of figuring out the right forms to fill out at the right times, as well as trying to keep up with ever-evolving policies, follow these DME billing guidelines for your orthopaedic clinic.

1. Collect Necessary Documents

Missing just one small item could result in a delayed payment. That’s why it’s imperative to ensure you’ve collected all the necessary documentation. This includes: 

  • Prescription– a written order from a medical practitioner that states the recommended DME a patient needs for their treatment
  • Certificate of Medical Necessity– a form verifying that the DME will be used for the treatment or prevention of disease; must be signed off on by the patient’s physician and the DME provider
  • Prior authorization and/or Written Order Prior to Delivery (WOPD)– Approval from Medicare for the prescribed DME; prior authorization is required to submit reimbursement claims and get paid for dispensing DME
  • Proof of Delivery– as of March 2020, a signed delivery slip is no longer a requirement for proof of delivery to limit contact between DME delivery drivers and equipment recipients; sometimes, a photo of the delivered DME and/or the recipient of the DME is required

As of January 2020, Medicare has replaced the WOPD with the Standard Written Order (SWO). An SWO must be completed and provided to a supplier before you can bill Medicare for any DME and include the following six elements:

  1. The beneficiary’s name or Medicare Beneficiary Identifier (MBI)
  2. Order date
  3. Description of the item, which can include a general description of the item (e.g. wheelchair, back brace), a Healthcare Common Procedure Coding System (HCPCS) code, a HCPCS code narrative, or a brand name and model number
  4. Quantity to be ordered, if applicable
  5. Treating Practitioner Name or National Provider Identifier (NPI)
  6. Treating practitioner’s signature

Note: Each piece of DME that will be separately billed must also be listed separately. 

2. Contact The Patient’s Insurance Provider

You are responsible for collecting any and all information about all possible forms of a patient’s possible insurance. This includes insurance they may receive from a family member or spouse’s insurance plan, worker’s compensation, or liability insurance. If your patient receives Medicare benefits but has another form of insurance, then Medicare is a secondary insurance provider, and you have to attempt to contact the primary insurance provider first.

You need to collect the name, address, and group policy number from the primary insurance policyholder, as well as the individual number, on group health plans if applicable.

A patient’s insurance information should be on their insurance card, which they should bring with them at the time of their appointment.

Then, contact their provider to determine what equipment is covered, whether your patient has met their deductible, whether there have been any changes to their insurance status, etc.

3. Code the Equipment

To file a claim, you must provide a description of the equipment you are providing to your patient. This description includes an HCPCS code.

HCPCS codes are standardized descriptions of different medical services and equipment, used by Medicare, Medicaid, and other insurance providers.

Temporary HCPCS codes are updated quarterly, and the permanent code set is updated yearly, which means you have to keep up with coding practices. You cannot simply copy codes for years—you have to keep up with provider updates.

Create an Invoice

An invoice is a document listing the: 

  • DME supplies you have obtained or will obtain for a patient
  • DME provider’s information
  • HCPCS code
  • Description of item(s)
  • Quantity of supplies
  • DME supplier’s requested price of each item
  • Subtotal (which does not include shipping and handling fees)

This invoice will help you when it comes to claim filing and in the event that your DME supplier practice gets audited. 

4. File the Claim

DME providers typically fill out form CMS-1500 before billing Medicare, Medicaid, Tricare, or another insurance provider. In addition to your patient’s insurance information and equipment codes, this form details:

  • The date(s) procedures, services, and/or supplies were provided
  • Any unusual circumstances that may require a modifier code such as equipment rentals or servicing fees; not all modifiers are required, but if a modifier is required and you do not include it, your claim may be denied and you may lose out on profits
  • Diagnosis code(s)
  • Prior authorization number
  • Service facility location information
  • Billing provider information
  • The total cost of listed procedures, services, and/or supplies provided
  • Signature of both patient/authorized person and physician/provider

There are also several other fields that depend on your patient’s particular circumstances. And, if you miss any of the required parts of this form, your claim will be denied.

You must file claims electronically unless your DME supply business has less than 10 full-time employees. 

To file claims electronically, you must have a computer that meets HIPAA requirements. You also must enroll in an electronic data interchange program, especially for Medicare/Medicaid claim submissions. Various insurance providers may have additional claims filing registration requirements.

Streamline Your Billing Efforts

If you want to avoid having to resubmit claims and wait for approval or be denied payment entirely, simplify and streamline your billing process with a dedicated DME supply management software and an experienced team.

Select Ortho’s revenue cycle management service will help your DME supplier business manage prior authorizations, review your coding and documents, enter charging and payment information, and follow up with insurance companies about collecting payment and resolving claims issues.

With our powerful, easy-to-navigate software and our guidance, our clients collect on 95-98% of claims filed, compared to the industry average of 50%.

Make sure your orthopaedic DME program always follows these essential DME filing guidelines by adopting a full-scale DME supply and billing solution. Then, you can focus on getting more patients in the door, and providing adequate care for each one.

IMPROVE YOUR PATIENT FLOW