Key Points:

CMS and Medicare are continuing to investigate and audit DME provided and supplied by medical providers.  They have concerns that they are finding in their audits that can result in recoupment of payment received by providers for the Durable Medical Equipment they have purchased, and then dispensed.  CMS has very specific guidelines on what should be documented for these supplies to prove medical necessity and prove that the patient did receive the item and understands how to apply and use it.  

Documentation Requirements for DME in the Medical Office


Durable Medical Equipment (DME) is used to treat conditions and injuries that patients are recovering from.  One way a patient can receive a DME is when the office purchases the DME from a manufacturer or distributor and then dispenses these items to patients.  CMS and Medicare require that the patients meet certain requirements for them to reimburse a provider for these items, and that the medical necessity for these items for a particular patient are met based on policies that have been created.  CMS and Medicare also require that the provider documents specific information in the medical record to meet their requirements, and also has proof the patient actually received the item and understands how to use the DME.  In circumstances that Medicare may not pay for an item, the patient has to be made aware of this when the item is given to them, and they have to sign an Advanced Beneficiary Notice (ABN) stating they understand their insurance may not cover the item, and they will be responsible.  CMS and Medicare have found that many offices are not obtaining the required documentation when dispensing DME.  This can result in CMS and Medicare asking for  the monies they have paid to the provider, sometimes with penalties, which becomes a financial loss for the provider who has paid for these items.  Understanding what is required by the provider is essential in the dispensing of DME to patients be a revenue stream for offices and not a loss.  

Areas covered in the session:
  • Stark Law
  • Policy Article Changes  
  • Article Changes November 2017
  • CMS Program Integrity Manual
  • DME Documentation requirements
  • Ordering/referring physician must be a Medicare-enrolled physician
  • Orders
  • Dispensing Orders
  • Detailed Written Orders
  • Medical Necessity Statement
  • Medical Records
  • 3 Types of Delivery  
  • Proof of Delivery
  • ABN
  • Modifiers KX
  • Potential to bill both KX and GA/GZ modifier
  • Modifiers KT-KY
  • Modifiers used with DME that is part of the Competitive Bidding Program 
  • Coverage Modifiers
  • CMS Reference
  • Terminology DME
  • DMEPOS= Durable Medical Equipment Prosthetics and Orthotics Services
  • CMS Definition Of Brace
  • Repair/Replace Orthotic
  • Orthotic Training
Who will benefit?

Coders, Billers, Physicians, Physician Assistants, Nurse Practitioners, Auditors

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