DME Billing Coverage Limitations and Exclusions 

Durable medical equipment (DME) billing is an essential aspect of revenue cycle management in the healthcare industry. As the industry evolves, DME has grown in importance and now serves millions of patients. However, managing the billing processes and reimbursements associated with DME can be time-consuming and labor-intensive.

DME billing is becoming more of an administrative burden for healthcare providers as regulatory requirements continue to grow. In fact, the DME billing process is prone to numerous mistakes and errors due to such complexities. If not addressed properly, these errors can result in claim denials or rejections, resulting in significant losses for the DME provider. Here are some of the most common DME billing requirements one must be aware of to receive the adequate reimbursement amount for the services provided.

What is DME Billing?

The process of generating and submitting claims for the durable medical equipment provided is called DME billing. However, DME billing does not cover equipment or devices that are used for convenience rather than a medical need of the patient.

What is DME Coding?

DME billing companies, data analysts, and coding specialists submit insurance claims using HCPCS (Healthcare Common Procedure Coding System) codes. This DME coding system contains a list of all the codes used in DME billing services. These codes aid in the tracking of supplies and equipment given to patients. As a result, Medicare and other insurers can process health insurance claims more efficiently. HCPCS code E0639, for example, denotes a moveable patient lift system.

DME Billing Coverage Conditions

DME billing services can be covered only when the following conditions are fulfilled:

  • When a patient has DME benefits and the equipment is recommended by a healthcare professional to treat or diagnose a long-term disease or illness, and the equipment is not otherwise excluded in the patient benefit plan document or history.
  • DME must not be consumable or disposable for DME billing unless absolutely necessary for the effective use of covered DME.
  • In the absence of disease, illness, or disability, the patient cannot use DME.
  • For outpatient use in home settings, DME must be provided or ordered by healthcare professionals.
  • DME must only be used for medical uses or medical purposes.

DME Billing Coverage Limitations

Being a DME biller, one should be aware of various DME billing coverage limitations. They can be as follows:

1. If a patient uses one or more DME to meet functional needs, coverage benefits are only applicable and available for one DME that meets the minimum patient requirements. They are as follows:

  • Custom wheelchair vs. standard power wheelchair
  • Standard vs. semi-electric vs. complete electric vs. floating bed

This limitation is intended to eliminate coverage for deluxe or additional components for a DME item that is not required to meet the minimal requirements of patients to treat the chronic disease or illness.

2. When a patient purchases or rents a DME that exceeds the guidelines outlined above, the patient is responsible for the cost difference between the items or devices purchased or rented.

DME Billing Coverage Exclusions

DME billing services cover all those accessories or devices that are primarily intended for the comfort and convenience of the patient. However, the following DME devices are not covered by insurance companies:

  • Air purifiers and filters
  • Air conditioners
  • Non-medical equipment batteries
  • Humidifiers
  • Non-medical mobility devices. This exclusion does not apply to coverage for Pediatric DME billing.
  • Remodeling or DME modification to home or vehicle to accommodate DME or a patient condition.

How to Streamline the DME Billing Process?

Streamlining the DME billing process can result in higher reimbursements for your medical practice. Outsourcing to your DME billing partner, such as 24/7 Medical Billing Services, is the best way to optimize your DME billing workflow! Outsourcing DME billing operations will allow you to benefit from the expertise of DME billing specialists. You can stay up to date on policy changes, payor guidelines, regulation updates, and so on. Moreover, these professional DME billers and coders can help you focus on your core expertise, providing quality healthcare to your patients. Reach our experts to know more about our DME billing services.

Read more: How To Reduce DME Billing Backlogs?

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