DME Claims vs. Medical Claims: Key Differences and Processing Tips

Exploring the world of durable medical equipment (DME) claims for physicians may be a complex and challenging undertaking. Understanding the difference between DME claims and medical claims is critical for realizing the significance that DME holds. Furthermore, there is a need on the part of healthcare providers or physicians to be aware of the processing tips associated with DME to ensure correct and timely payments. Let’s have a deep insight into the core concepts for maximizing the reimbursements:

DME Claims vs. Medical Claims

The primary difference between DME and medical billing claims is that DME billing necessitates a more in-depth understanding of diverse medical circumstances and specialized DME items than regular medical billing and coding.

The significant differences between the two claims are listed below.

1. Use of Codes:

DME claims require the use of a variety of HCPCS Level II codes. On the other hand, HCPCS Level I codes are used for medical claims.

2. Use of Modifiers:

DME billing claims necessitate the use of modifiers and determine whether a claim is approved or denied. At the same time, modifiers are mostly optional, as they have no direct impact on whether or not a claim is approved.

3. Reimbursement Maximization:

To claim DME billing, reimbursement is a complicated and time-consuming process; a minor error could result in a denied claim. In contrast, reimbursement is typically based on revenue codes or procedure codes in medical billing claims.

Processing Tips for DME Claims:

• Documentation Related Tips

Proper documentation is essential in the DME claims processing procedure as it serves as the foundation for assessing the medical necessity of the equipment and ensuring that it satisfies the patient’s needs. The following are essential documentation requirements:

1. Physician’s Prescription:

All DME claims require a documented order from the treating physician. The diagnosis of the patient, the type of DME required, and the duration of use should all be included in the prescription.

2. Medical Records:

Providers must keep detailed medical records that substantiate the DME’s medical necessity. This may consist of lab results, progress notes, and diagnostic reports.

3. Proof of Delivery: 

Suppliers must provide the patient with proof of delivery, which may include electronic tracking information or a signed delivery receipt.

4. Detailed Written Order (DWO):

A comprehensive written order from the treating physician is necessary for frequently abused or certain high-cost DME items. The DWO should include a full explanation of the item, the patient’s diagnosis, and the equipment’s medical needs.

• Billing Related Tips

Providers can submit DME claims for reimbursement after completing the relevant documentation and coding. Among the most crucial billing techniques are:

1. Electronic Claims Submission:

Most insurance carriers, including Medicaid and Medicare, mandate electronic claims submission for DME services. Providers should become acquainted with their respective carrier’s electronic data exchange (EDI) standards and regulations.

2. Timely Filing:

Providers must file their DME claims within the carrier’s stated timely filing window, which for Medicare claims is typically 12 months from the date of service.

3. Claim Denials and Appeals:

If a DME claim is denied, providers should thoroughly evaluate the reason for the denial and take the necessary steps to remedy any errors or submit further documentation. Providers may file an appeal with the insurance company to dispute the denial if required.

• Coding Related Tips

Accurate coding is also critical for DME claims processing as it guarantees that the equipment is correctly billed and reimbursed at the correct rate. Healthcare Common Procedure Coding System (HCPCS) codes, which are used to designate DME items and services, should be familiarized with by providers.

1. HCPCS Level II Codes: 

These alphanumeric codes are used to identify specific DME items such as oxygen equipment, wheelchairs, and diabetes supplies. Providers should use the most specific code available to characterize the item being billed.

2. Modifiers:

Modifiers are two-digit codes that provide further information about a DME item or service. They can be used to distinguish between rental and purchasing, new and old equipment, or other particular circumstances.

Outsourcing DME Claims:

Do you find it challenging to manage the complexities of DME claims processing?

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24/7 Medical Billing Services’ skilled staff is committed to assisting DME providers like you in streamlining claims processing, increasing reimbursement rates, and remaining in compliance with industry rules. In fact, you can concentrate on providing excellent care to your patients by working with us while we handle the complexities of DME billing and coding.

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See also: Complying With Payer-Specific SWO Requirements In DME Billing