DME Billing Services
Prospect Healthcare Solutions offers expert DME Billing Services designed for smooth, accurate, and efficient medical billing processes. We help healthcare providers who provide Durable Medical Equipment (DME) to patients get paid in a timely manner through Medicare, Medicaid, and private insurance companies.
Outsourcing your DME Medical Billing Services to us allows you to reduce administrative work, avoid billing mistakes, and spend more time caring for your patients while we take care of the complexities involved in the billing process.
We possess industry-standard billing systems in addition to a team of highly qualified and proficient professionals within each field of expertise. We have complete management services from verification of patient eligibility through claim denial management and the corresponding follow-up processes.
By outsourcing your DME billing to our company, you will not only reduce the administrative burden placed on your practice, but you will also improve your cash flow since we will take care of complex transaction processes associated with DME billing.
DME Payer Rules We Manage
Beyond codes and modifiers, DME claims depend on what equipment the patient already has, where the patient is, and how supplies are refilled. These are the payer rules our revenue cycle management team handles for DME suppliers:
Same or similar equipment
What it means: Medicare won’t pay for an item when the patient already has the same or similar equipment from another supplier, such as a second hospital bed or wheelchair.
How we handle it: We run a same-or-similar check through the DME MAC before delivery, so the supplier knows about a conflict before the item goes out.
Inpatient, nursing facility and hospice stays
What it means: Equipment isn’t paid separately while the patient is an inpatient or in a covered skilled nursing facility stay. Items can be delivered up to 2 days before discharge for fitting and training, and billed for the discharge date.
How we handle it: We check admission and discharge dates before billing, and set the date of service to the discharge date for pre-discharge deliveries.
Refills and resupply
What it means: Supplies can’t be shipped automatically. The supplier must contact the patient no sooner than 14 days before delivery to confirm the need, and ship no sooner than 10 days before the current supply runs out.
How we handle it: We track refill dates and keep the patient’s confirmation with each order, so resupply claims hold up on review.
Replacement and repairs
What it means: Medicare expects equipment to last at least 5 years. It replaces an item sooner only if it is lost, stolen or damaged beyond repair. Repairs of patient-owned equipment are billed with modifier RB.
How we handle it: We check the item’s age and the reason for replacement, and document police or incident reports and repair estimates when needed.
Medicaid and secondary payers
What it means: Medicaid and commercial plans have their own rental, purchase and authorization rules. When Medicaid or another plan is secondary, it needs the Medicare payment or denial first.
How we handle it: We bill each payer by its own rules, and send crossover and secondary claims with the primary payer’s remittance.
Medical review requests
What it means: Medicare contractors audit DME suppliers often, through additional documentation requests (ADRs) and targeted reviews. Medicare ADRs usually allow 45 days to respond, and unanswered requests are denied.
How we handle it: We gather orders, medical records and proof of delivery for each request and send them before the deadline.
A Common DME Denial and How We Fix It
Example: a CPAP rental denied after the first 3 months
The denial. The fourth rental month of a CPAP device (E0601 with KH and KX) is denied with CARC 50 (not medically necessary) because the record doesn’t show the patient is using it.
How we fix it:
- Get the usage data. We download the device’s compliance report and check for use of 4 or more hours a night on 70% of nights in a 30-day period during the first 3 months.
- Check the re-evaluation. Medicare needs a face-to-face visit between day 31 and day 91 where the treating practitioner notes that symptoms improved and the patient is using the device.
- Correct or appeal. If both are on file, we send them with a reopening or appeal. If they aren’t, coverage can’t continue until the patient meets Medicare’s requirements again.
- Prevent the next one. We track compliance and re-evaluation dates for every new CPAP patient from day one.
Example: a hospital bed denied as same or similar equipment
The denial. A semi-electric hospital bed (E0260) is denied because Medicare’s records show another supplier is already renting a bed to the patient.
How we fix it: we confirm the other rental with the DME MAC and ask the patient whether that bed was returned. If the first rental ended, we send the pickup date and resubmit. If the patient needs a different bed because their condition changed, we document the change and the new order. Going forward, our denial management team makes a same-or-similar check part of every intake.
Our DME Billing Process
We follow a structured approach to ensure efficiency and accuracy in all DME billing services:
Data Capture
We actively document and input patient & billing information into our databases. Data input accuracy helps to eliminate errors, decreases the time it takes to process a claim, and increases the amount of money reimbursed.
Claims Filing Assistance
We submit claims to Payers for reimbursement in accordance with the Payers’ guidelines. Our staff guarantees that the submission of all claims is accurate and sent to the Payer on an agreed-upon date so that there are no delays.
Denial Management
We monitor and review all claims and look for denials by finding the cause behind denials of claims and appealing denied claims. In addition to using appeals, we identify ways to prevent future claims from being denied through the use of preventive measures.
Payment Posting and Auditing
We ensure all payments are posted properly, as we audit payments on a daily basis to identify and correct discrepancies. Our audit procedure is designed to maintain accurate accounting and to make timely corrections to the bookkeeping system.
Insurance Eligibility Verification
Prior to providing any services, we confirm patient insurance eligibility to maximize the likelihood of reimbursement for the services provided. This step helps reduce claim denials and speeds up the payment process.
Practice Statements
We provide detailed billing statements to the practice outlining all billable activities, claim submissions, and outstanding balances on unpaid claims. These reports allow the practice to clearly identify and monitor their financial status at any given time.
Fee Schedule Updates
Your fee schedules are routinely updated to incorporate the most recent-year payer and regulatory changes so that you can bill accurately and optimize the amount you receive back.
Custom Report Development
We have reports customized to each practice. Some examples of these reports are billing trends, unpaid accounts with dates due, and performance metrics. These reports can help identify ways to improve the operation of your practice.
Durable Medical Equipment (DME) Billing Claims Audits
At Prospect Healthcare Solutions, DME billing services and claims audits are a vital part of accurate and clean billing processes. These audits help identify incorrect, incomplete, or duplicate claims that cause payment delays or denials. We check every detail of the billing claim, including patient information, equipment codes, and insurance policies, to avoid any issues with reimbursements. By strengthening the DME revenue cycle, our main concern is to submit claims on time and meet all payer guidelines and compliance standards.
At Prospect Healthcare Solutions, we handle billing for healthcare providers who supply or recommend Durable Medical Equipment (DME) to patients. Whether it’s a wheelchair, oxygen device, or any other approved equipment, our durable medical equipment DME billing services ensure accuracy and timely submission. Many providers choose to outsource DME billing services to us because we stay updated with the latest regulations and make sure every claim is processed correctly to reduce rejections and improve reimbursement speed.
What Are DME Billing Services?
Durable Medical Equipment (DME) billing services comprise processed claims and payments along with information pertaining to the above mentioned piece of medical equipment.
Examples of Durable Medical Equipment include, but are not limited to, Wheelchairs, Oxygen Devices, (Hospital) Bed and any other equipment that is deemed appropriate for use as DME.
Proper DME billing guarantees that your office receives the appropriate amount of reimbursement from the insurance company in a timely manner.
The following items are taken care of by our team.
- Verification of benefits with the payer
- Coding billed correctly
- Submission of insurance claims
- Posting payments for the insurance claim
No matter if you require stand-alone DME billing services or would like assistance with an end-to-end billing solution, we offer several customizable options to fit your needs.
Why Choose Prospect Healthcare Solutions for DME Billing?
Healthcare providers encounter numerous hurdles due to their internal DME revenue cycle management processes. Such errors as incorrect coding, missing deadlines, etc., can impact reimbursement payments and cash flow.
By outsourcing your billing to Prospect Healthcare Solutions, you benefit from:
Fewer Billing Errors
Our highly-trained professional team verifies claims before processing through auditing procedures, ensuring they are complete, accurate & compliant. This leads to reduced denials & rework.
Faster Reimbursements
We submit clean claims quickly because we want to help your practice maintain positive cash flow.
Reduced Administrative Burden
Your staff/office can concentrate on providing quality healthcare, while we will take care of the billing activities.
Regulatory Compliance
We continually monitor and remain abreast of all recent legislative updates as they relate to Medicare/Medicaid and Private Payers.
DME HCPCS Codes, Rental Modifiers and Medicare Supplier Rules
DME suppliers bill under different rules from physician practices: HCPCS Level II codes, rental and purchase modifiers, written orders and proof of delivery, all processed by a separate group of Medicare contractors.
| Service | Codes and rules | What we check |
|---|---|---|
| HCPCS Level II codes | E-codes for equipment (for example E0601 CPAP), L-codes for orthotics and prosthetics, A-codes for supplies, K-codes for some items | The code matches the item and its exact features, so claims are not downcoded |
| Rental and purchase modifiers | RR rental, NU new purchase, UE used purchase; KH, KI and KJ for capped rental months | Each month of a capped rental is billed with the right modifier |
| Capped rentals and oxygen | Medicare pays most capped-rental items for 13 months, after which the patient owns the item; oxygen equipment is paid for 36 months | Rental month counts are tracked so billing stops at the cap |
| Orders and documentation | A standard written order with the required elements before billing; some items also need a face-to-face visit and a written order before delivery | Orders, medical records and proof of delivery are on file before the claim goes out |
| Medical necessity modifiers | KX when coverage criteria are met; GA when an ABN is on file; GZ when no ABN was obtained | Modifiers match the documentation and ABN status |
| Prior authorization | Required by Medicare for items on its Required Prior Authorization List, such as some power mobility devices and orthoses, and by many commercial plans | Approvals are in place before delivery |
| DME MAC jurisdictions | Medicare DME claims go to the DME MAC for the patient's state, not the Part A/B contractor | Claims are routed to the right contractor |
| Supplier enrollment | Medicare DMEPOS suppliers must be accredited and post a surety bond | Enrollment and accreditation are current before Medicare claims are sent |
We also handle patient responsibility after insurance, resubmissions and appeals, and reporting by payer and item type.
Common DME Codes We Bill
These are some of the items we bill most often for DME suppliers, with the rule that most often causes a denial for each:
| Item | HCPCS code | Rule we check |
|---|---|---|
| CPAP device | E0601 | Capped rental; Medicare continues coverage after the first 90 days only with documented use of 4+ hours a night on 70% of nights in a 30-day period |
| CPAP masks | A7030 full face, A7034 nasal | Replacement frequency limits per payer |
| Bilevel (RAD) device | E0470 without backup rate, E0471 with backup rate | Qualifying sleep study or respiratory diagnosis for the device chosen |
| Oxygen concentrator | E1390 | Paid as a 36-month rental; qualifying oxygen saturation or blood gas result is on file |
| Portable oxygen | E0431 portable gaseous system | Portable need is documented, not just stationary oxygen |
| Semi-electric hospital bed | E0260 with mattress | Capped rental; medical need for position changes is documented |
| Standard wheelchair | K0001 | Capped rental; mobility limitation in the home is documented |
| Folding wheeled walker | E0143 | Purchase or rental option recorded correctly |
| Lumbar-sacral orthosis | L0650 | Off-the-shelf vs custom-fitted code and fitting notes |
| Knee orthosis | L1833 | Some knee and back orthoses are on Medicare's prior authorization list |
| Blood glucose test strips | A4253 per 50 strips | Quantity limits depend on whether the patient uses insulin |
| Negative pressure wound therapy pump | E2402 with supplies A6550 | Wound measurements and progress are documented each month |
DME Billing FAQs
What codes are used for DME billing?
HCPCS Level II codes: E-codes for durable equipment, L-codes for orthotics and prosthetics, A-codes for supplies and some K-codes, with modifiers for rental or purchase.
How do capped rentals work under Medicare?
Medicare pays a monthly rental for most capped-rental items for up to 13 months, then the patient owns the item. Each month is billed with a modifier showing which rental month it is.
What documentation does a DME claim need?
A standard written order, medical records that support the item, and proof of delivery. Some items also need a face-to-face visit and prior authorization.
What is the KX modifier in DME billing?
It shows that the supplier has documentation proving the item meets Medicare's coverage criteria. Using it without that documentation is a compliance risk.
Contact Us for DME Billing Services
We know the individual requirements of DME billing for small suppliers. Our services have been established to assist small practices with efficient claim processing, rather than having to employ a complete team of billers; therefore, assisting smaller suppliers in staying competitive and creating steady cash flow.
At Prospect Healthcare Solutions, our affordable DME billing services are provided without sacrificing quality. Our objective is to provide you with compliant and accurate billing, resulting in an increase in your revenue; while keeping your costs within reason.
We provide a full DME revenue cycle management service and/or provide you with as much or as little as just your billing support; we will ensure that your claims are submitted on time, your payments are posted correctly, and you will have access to all forms of reporting.
Contact us today to start streamlining your DME's billing.