Understanding how to choose the correct DME CPT codes by medical practices is the key to a healthy revenue cycle management. A slight confusion can lead to lengthy appeals and litigation processes, leaving your earning in a limbo. A common misconception that all durable medical equipment falls under current procedural terminology (CPT) codes is the biggest culprit and responsible for up to a 90% claim denials.
This blog will discuss when and what CPT code for durable medical equipment services should be used. This guide will clear misconceptions and help you choose the correct DME codes. By separating service CPT codes from HCPCS codes, you can ensure precision of clinical documentation and higher clean claim rate.
CPT Codes vs. HCPCS Level II for Durable Medical Equipment
Having a deeper understanding between service CPT codes and durable medical equipment codes can guarantee whether you will be paid for services or work for free. Here’s how you can differentiate them from each other:
The 5-Digit Service Code (CPT)
CPT (current procedural terminology) codes are five digit codes that are managed and upgraded annually by AMA (american medical association). These codes provide the description to the payer about what services including procedures, diagnostic test providers have performed during the encounter.
HCPCS Level II Codes: What the Patient Takes Home
HCPCS (Healthcare Common Procedure Coding System) DME codes in medical billing are maintained by CMS and based on alphanumeric standards. These codes are used when a patient is provided with a glucose monitoring device, electronic blood pressure monitor, walker, nebulizer, a C-PAP machine, etc. When a patient is given new equipment, modifier NU for DME is used.
How Providers Use CPT Codes for DME Services
The level of accuracy for DME coding and billing depends on how precisely you have separated HCPCS Level II codes from your professional services. HCPCS codes can only be used for physical equipment you have provided to patients, it is not reimbursable for encounter and training services.
To ensure you’re paid for evaluation and training patient how to safely use equipment, you must use accurate specific service-based CPT codes:
Orthotic and Prosthetic Management
Care services related to orthotic and prosthetic management use the following CPT codes:
CPT 97760:
This CPT code is widely used in podiatry practices involving encounter for training, fitting and measurement for orthotic devices like braces, and inserts.
CPT 97763
For subsequent patient visits where you have to modify, change or assess the performance of already provided orthotic equipment, CPT 97763 is used. This CPT code also covers advance training provided to the patient.
Remote Physiologic Monitoring Setup
For remote patient monitoring through digital devices, their set-up at home and data collection training use the following CPT codes:
CPT 99453:
This code is used for first time home set-up, training, and device handover and does not cover repeated visits.
CPT 99454:
This CPT code covers the transmission of data through mobile networks, recording of health records and integration with the provider’s EHR system.
Having a command on orthotic and RPM coding ensures, every minute you spend with the patient is reimbursed.
Coding the Hardware: Navigating HCPCS Level II
Medical practices directly dispense DME to patients from their inventory, must use HCPCS II code to accurately bridge the encounter and durable medical equipment services. These are the two categories that cover the entire range:
E‑Codes: Core Durable Medical Equipment
DME items designed for repeated use are covered by E-codes like E0143 for walker and E0601 for a C-Pap machine. These codes only cover physical items safely handover to patients, but require CPT code for training and provider’s encounter time.
L‑Codes: Orthotics & Prosthetics
L-Codes are widely used to cover orthotics and prosthetic devices like artificial limbs, inserts for diabetic foot care, spine alignment braces, etc. These high-value claims can trigger denial if they are missing L-codes.
The Ultimate Check: Essential Modifiers
Without appropriate dme codes and modifiers, a claim is incomplete. Here are the two categories of modifiers commonly used for durable medical equipment:
-NU (New Equipment
If a patient is provided with a brand new DME item then use this modifier.
-RR (Rental):
When DME items are provided to patients on a short-term period on a monthly, weekly basis, use this modifier that helps payers classify them as rentals.
3 Rapid-Fire Tips to Prevent DME Claim Denials
DME claims are one of the most scrutinized ones in the healthcare industry due to their high-dollar billing. Here are the 3 ways to comply with payer policies and protect your practice from audits:
1. Check the Dispensing Entity
If you’re dispensing the DME item directly to a patient from your hospital, you can bill the item and charge payers. If a dispensing entity is an independent medical store, you can only prescribe the item but cannot charge other than encounter services.
2. Document Medical Necessity Clearly
Your clinical documentation must explicitly mention why the specific DME you have prescribed is medically necessary and what role it will play in improving quality of life for the patient. Accurately binding the entire symptomatology with future improvements help payors understand the nature of treatment.
3. Watch for Prior Authorizations
Commercial payers almost always require you to obtain prior authorization for high-dollar DMEs like powered wheelchairs, artificial limbs, hospital beds, C-Pap & Nebulizer machines. It’s best to check the rules for specific payers before offering DME to patients. Doing this will help you offer only approved products listed in the health plan.
Conclusion
Accurate use of CPT code for durable medical equipment is not necessary, it also protects your practice from payer audits. Remember the golden rule of DME billing, always use CPT code for your services, and HCPCS II codes for that specific equipment you have provided to the patient. Separating supplies from the services help insurers understand what type of service you have performed and who is the real vendor for durable medical equipment.
This way you can minimize denials and keep your revenue steady with minimal disruptions. Is your practice receiving DME claim rejections? At Connecticut Medical Billing, we help podiatry and wound care practices tackle the payer policies and scrutinies with ease. Let our DME billing experts lower your claim denials and increase profitability so you can focus on patient care.