Medicare Part B (Medical Insurance) covers medically necessary durable medical equipment (DME). DME must be used for a medical reason, long-lasting, with an expected life time of at least 3 years. The doctor or treating practitioner must prescribe the type of equipment the patient needs by filling out a detailed written order. Equipment that is covered by CMS include commode chairs, continuous passive motion (CPM) machine, crutches, hospital beds, oxygen equipment and accessories, patient lifts, traction equipment and walkers.
An assignment will be made between the person with Medicare, Medicare, and doctors or other health care providers, and suppliers of health care equipment and supplies. Doctors, providers, and suppliers who agree to accept assignment accept the Medicare-approved amount as full payment. Patients pay the doctor or supplier the coinsurance (usually 20% of the approved amount). Medicare pays the other 80%. CMS uses the Comprehensive Error Rate Testing (CERT) program for claim submission, processing and payment.
Most Orthotic and Prosthetic (O&P) claims are denied mainly due to errors in documentation. A detailed DME insurance verification procedure can help physician to receive the right reimbursement for the services rendered. A recent presentation by the representatives from the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) at the American Orthotic and Prosthetic Association National Assembly provides some guidelines and tips for O&P facilities to improve their claims with accurate documentation.
In a review from the 2013 and 2014 claims, it was found that the error rates for lower limb orthoses and lower limb prostheses increased for Region A and B, while it decreased for B and D. While medical records were the top reason for errors in lower limb orthosis claims, replacement records were the top reason for errors in lower limb prostheses claims.
If there is an error on a claim, the CERT contractor will send the claimant an over payment demand letter. To appeal, the claimant needs to file a redetermination within 120 days. Certain tips highlighted in the presentation are:
- Many orders are denied due to illegibility. Patient’s physician or nursing practitioner should provide the DME order via photocopy, facsimile image, electronic document or original “pen and ink” document.
- A verbal dispensing order should be documented and followed up by a detailed written order which includes a description of the item, beneficiary’s name, physician’s name, date of the order date, start date and the signature of the practitioner supplying the device.
- A claim submitted without an order should have an “EY” modifier to indicate there is no qualifying health care professional to provide the order. Practitioners should take responsibility for their order error rates.
- Patient’s medical records must reflect a need for the care being provided. Documentation should be complete. For instance, documentation for lower limb prosthesis should include functional limitations and capabilities, including ambulation; expected functional potential or differences; clinical course; prognoses; and past experience with related items.
- Medical history should include co-morbidities related to amputation, current or prior use of ambulatory assistance, musculoskeletal and neurological examinations and diagnosis-causing symptoms.
- DME procedure HCPCS codes and modifiers in claims are crucial. Description in physician notes should support the codes chosen by the prosthetist
- O&P offices should keep the records of proof of delivery on file for 7 years. All proof of delivery forms should include a sufficient description of what was provided and the number of items
- Documentation for both off-the-shelf (OTS) and custom-fitted orthoses must include details of the product specified by the ordering physician; physician’s medical record that justifies the need for that type of product and codes that differentiate both
Repair Devices
Medicare may also cover repairs and replacement parts. It will pay 80% of the Medicare-approved amount for purchase of the item. Medicare will also pay 80% of the Medicare-approved amount (up to the cost of replacing the item) for repairs. Documentation from the supplier or the physician should explain the need for the repair: why it is necessary and what happened to the device.
As the repair codes are general, practitioner should indicate in the record what the specific device is and which part is being repaired or replaced. O&P Offices should remain aware of specific repair HCPCS codes, such as
- L7510 – Repair of prosthetic device, repair or replace minor parts
- L7520 – Repair prosthetic device, labor component, per 15 minutes
- L4210 – Repair of orthotic device, repair or replace minor parts
- L4205 – Repair of orthotic device, labor component, per 15 minutes
The labor code may only be used for time involved in the actual repair or for medically necessary adjustments made more than 90 days after delivery.
DME medical billing specialists performing documentation for busy Orthotic and Prosthetic practitioners should have excellent knowledge of applicable medical codes and must adhere to CMS guidelines so that claim denials can be prevented.
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