Durable Medical Equipment - DME Coding

Patients come to your office looking for answers to their pain or lack of function. It’s critical that a doctor doesn’t do what one of my clients admitted to recently…“X-raying the patient’s wallet.”

Your patients both deserve and expect your best recommendations. If you provide products or services and are withholding your recommendation because you think the patient may not be able to afford that, it is simply inappropriate. Providers should prescribe what the patient needs, and the team members’ job is to help the patient pay for these items according to your financial policy.

Stabilizing orthotics

Once such profit center that mirrors a patient’s needs is stabilizing orthotics. The number of miles the average person walks in a lifetime, about 110,000 miles, is the equivalent of five trips around the Earth. And it’s estimated that more than 90% of patients overpronate. Some patients see this as a discretionary choice in their treatment plan and others will immediately grasp the necessity.

Seven times out of 10, finances will be a key factor in a patient’s choice to obtain orthotics. Take the guesswork out of this subject by building tremendous perceived value for the necessity of the orthotic, fit the costs into their budget, and you’ll bridge that financial chasm. The doctor’s recommendation is key!

Should I bill insurance for products?

Many insurance carriers cover durable medical equipment (DME), including orthotics. They may require that DME orders go through an approved and contracted DME supplier.

Our experience shows that most offices do not properly verify insurance coverage. Instead, they simply check eligibility and get a general outline of benefits. When a practice provides a robust number of services, including DME like orthotics, a more detailed verification is required. We must dig into the details of coverage like never before or be stuck with an unpaid claim.
You need to:

• Ensure your current verification form prompts you to ask the more detailed questions on every insured patient.
• Verify all benefits for every patient, for all the services that may be recommended. Then you’ll know up front how to help the patient understand their potential financial responsibility.
• Locate the payer’s medical review policy on their website to supplement your verification. Here, you’ll find information about covered DX codes, referrals needed, etc. Sometimes, orthotics are only covered for foot and ankle conditions, and not the spinal stabilization that you may be prescribing for. Search for “orthotics and prosthetics medical review policy.”
• Make sure you won’t need a referral in order to have the DME paid by the carrier.

If you find that the DME you’re prescribing is not covered by the patient’s carrier, does that mean the patient doesn’t need it? Of course not! Help the patient understand the need for orthotics within your treatment plan, and then offer ways to afford them out of pocket.

For example, if you scan the patient’s feet, the visual that is provided helps the patient “see” the problem, much like X-rays do. It goes a long way toward helping the patient see the medical necessity of the doctor’s recommendation.

Coding and descriptions

Even if the patient is paying cash for the DME prescribed, code it correctly in your billing system. The patient may elect to submit to a Health Savings Account (HSA), a Health Reimbursement Account (HRA) or some other type of non-insurance reimbursement. Don’t choose product codes willy-nilly.

For some example durable medical equipment coding tips, there are many different codes to describe stabilizing orthotics. Each code describes different arch types, molding methodology and other details. If you propose a custom-made, stabilizing orthotic created from a patient scan, for example, that code will be different from one that simply heats up plastic and molds it directly to the patient’s foot.

Coding for DME is usually found in the Health Care Procedural Coding System (HCPCS), pronounced “hick-picks.” These are the codes that typically begin with a letter and are used to describe durable medical equipment. Be sure you bill the correct number of codes.

For example, when billing the orthotic supply code, you must bill two line items to indicate both right and left side. The code billed represents only one, thus the indicator “each.” Don’t make the mistake of billing this code only once.

Prescribe ancillary services if appropriate

Keep in mind that when prescribing DME, other ancillary services may be appropriate to include in your plan as well. Your services in the office are valuable and should be charged and paid. Implementing more orthotics in the practice, for example, might also increase the amount of taping or extra-spinal manipulation you perform.

Prescribing a pillow or lower-back support may require an instructional session for proper use.

These are important reminders for ordering and billing these types of services:

Kinesiology taping is usually considered experimental and investigational by most carriers. Include it in your plan as an out-of-pocket service in these cases. We suggest billing 97799 for the taping service, and then charging for the tape, per 18 inches. Use A4450 if using non-waterproof tape and A4452 if waterproof.

If treating one or more extra spinal regions along with the spinal adjustments, report 98943. The five extra spinal regions are head, upper extremities, lower extremities, anterior ribs and abdomen. Be sure you use it only once per encounter, no matter how many regions are treated.

Report code 97760 the day you dispense orthotics. This includes the one-on-one time the provider spends in fitting the orthotics in the patient’s shoes, explaining break-in schedules, watching the patient ambulate, etc. Because this is a time-based code, include time spent and remember to add it together with other time-based codes billed the same visit.

When dispensing DME, it may be necessary to include therapeutic exercises to restore strength, range of motion and flexibility. Use code 97110 when there is a documented loss or restriction of joint motion, strength, functional capacity or mobility being addressed with exercises. Use it to ease adaptation time by breaking up fixations and strengthening weak muscles in the feet. Have patients exercise by rolling a golf ball or pulling a towel with their toes. Both can be done in the office under direct supervision, and at home.

Prescriptions are powerful

Not all patients have full insurance support for their services in your office. Whether they have partial coverage, no coverage or even a high deductible, that doesn’t mean the patient doesn’t need what you recommend.

Here are some ways you can help make DME and ancillary care affordable when insurance support is not there:

Package all the services for the patient. Consider the total charges for the DME and the associated care. Bundle the charges into a single estimated out-of-pocket amount. Allow the patient to make monthly payments, using an auto-debit system, toward their balance. Ask the patient to pay some down payment toward your cost when ordering. Be sure the down payment covers your costs. Then let them work the remainder into a budgeted payment plan.

Encourage the patient to utilize programs like HSAs, HRAs and other employer-assisted plans that help cover the cost of products and services. Use a network-based discount for out-of-pocket care, such as a Discount Medical Plan Organization. This provides a legal way to discount for members of a plan who must pay cash.

Be creative with your payment plans but, above all, don’t forget the patients’ needs. Find a win-win situation and make DME and orthotics a part of your regular patient care. Include these wonderful profit centers in your practice that are so necessary for the patients.