A few things in life are exceptionally easy and straightforward. Unfortunately, purchasing things such as splints, prosthetics, and durable medical equipment (DME) – and figuring out which orthotics are covered by insurance – isn't so cut and dried. In fact, a ton can turn out badly with regards to orthotics and prosthetics billing. Thus, to make sure your patients get with they need – and you get paid what you merit – stick to the accompanying rules. The information beneath alludes to how Medicare reimburses for prosthetics and orthotics and doesn't necessarily reflect how commercial payers repay for these medications. At the same time, many commercial insurance payers align themselves with Medicare policies, so this should fill in as a decent general guide.
For prosthetics, Medicare reimbursement includes evaluation, fitting, parts and labor, repairs due to normal wear or tear within the initial 90 days of the delivery date, and adjustments made during the fitting and within the initial 90 days of the delivery date (not including adjustments welcomed on by changes in the remaining appendage or a patient's degree of function).
For orthotics, Medicare reimbursement includes evaluation, measurement and/or fitting, fabrication and customization, materials, cost of labor, and delivery.
HCPCS Code and Modifier Combinations
Knowing which modifier to use with a given HCPCS code can be tricky. Many HCPCS codes require a modifier to inform us as to whether the item is being rented (RR), purchased new (NU), or purchased used (UE). On the off chance that you present a claim without a RR, NU, or UE modifier for an HCPCS code that requires one of these modifiers, your claim will be rejected. To help you, we've assembled a couple of tips to help you make sure you have the modifiers you need on your claim.
The DME MAC Jurisdiction C Supplier Manual, Appendix A contains a rundown of HCPCS codes with their Payment Category. On the off chance that the code falls into one of the accompanying categories, at that point it will require a RR, NU, or UE modifier:
- Inexpensive or Routinely Purchased (IRP) Item
- Capped Rental Item
- Items Requiring Frequent and Substantial Servicing
- Oxygen Equipment (not contents)
An easy way to decide whether a RR, NU, or UE modifier is required is by looking into the HCPCS code on the CMS DMEPOS Fee Schedule. In the event that the fee schedule shows a modifier close to the HCPCS code, at that point, that modifier is needed for claim accommodation. When there are multiple modifier prospects (such as RR, NU, or UE), at that point the HCPCS code will be recorded on multiple occasions with a different modifier close to each code. Note that there are exceptions to this standard.
For instance, certain capped rental items that can be purchased in the primary month don't have a NU or UE value on the fee schedule. Also, note that inclusion or exclusion of a fee schedule amount for an item or service doesn't suggest any health insurance coverage.
Proving Medical Necessity
A Certificate of Medical Necessity (CMN) or a DME Information Form (DIF) is a form needed to help document the medical necessity and other coverage criteria for selected DMEPOS items. CMNs contain Sections A through D. Sections An and C are completed by the supplier and Sections B and D are completed by the physician. A DIF is completed and endorsed by the supplier. It doesn't need a narrative description of the equipment and cost or a physician's signature.
The accompanying forms underneath have been approved by the Office of Management and Budget (OMB):
- CMN CMS-484 – Oxygen
- CMN CMS-846 – Pneumatic Compression Devices
- CMN CMS-847 – Osteogenesis Stimulators
- CMN CMS-848 – Transcutaneous Electrical Nerve Stimulators
- CMN CMS-849 – Seat Lift Mechanisms
- CMN CMS-854 – Section C Continuation Form
- DME Information Form CMS-10125 – External Infusion Pumps
- DME Information Form CMS-10126 – Enteral and Parenteral Nutrition
Billing for TENS Units
Billing for TENS units is somewhat trickier than billing for different pieces of DME. In fact, it can even be difficult to receive reimbursement for TENS units, as nearly half of all claims for TENS units are denied. Reasons for those denials: Incorrect billing procedure and the claim failed to demonstrate medical necessity.
To start, you should obtain a written order prior to delivery (WOPD) before you can even hand over the unit and give the DMERC a CMN. Furthermore, as far as Medicare is concerned, there are just two reasons why a patient would have to purchase a TENS unit: acute post-op pain and chronic pain. In this way, make sure your CMN legitimizes one of these conditions to receive payment.
Additional Tip:
As long as the supplier is DME certified, the supplier will charge the patient for a "rental" payment of 10% of the purchase price – less coinsurance and/or any deductible is allowed – for the initial two months of utilization. This is essentially a trial period, which allows the attending physician to decide if the patient necessities to actually purchase the unit.
On the off chance that the physician considers it medically appropriate, at that point, everything for the unit will be due (the carrier won't adjust this amount for the two regularly scheduled payments). You can then bill your DMERC for the two-month rental period as well as the actual purchase.
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