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Billing Tips: Durable Medical Equipment (DME)
When you bill with a listed code (a code with a price on file):
- An invoice or catalog is not required with your claim.
- The claim does not require manual pricing.
- The claim can be billed electronically.
Remittance Advice Details (RAD) Claim Denials
RAD code 0095: This service is not payable due to a procedure, or procedure and modifier, previously reimbursed.
- If you bill a rental DME procedure code with a rental modifier that has already been paid for the same month and year of service, it will not be payable. Ensure that you are billing the correct code(s) and modifier(s). Exception: if there is an authorized TAR or SAR for additional quantities for the DME rental code.
- There are select wheelchair accessories that are not separately payable when billed in the same month of service as manual, motorized, or power wheelchair bases by any provider.
- There are select equipment procedure codes that are not separately reimbursable when billed with supply procedure codes by any provider.
- Verify the service code billed. You may have used an unlisted code when a listed code is available. Please check the Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates section in the Part 2 manual.
- Verify the modifier code billed. You may have used an incorrect modifier. Please see the Modifiers: Approved List section in the Part 2 manual.
- When billing for the purchase of wheelchair batteries, use modifier -NU only.
- Ensure your code(s) and modifier(s) on the claim match the Treatment Authorization Request (TAR)/Service Authorization Request (SAR)/eTAR.
- Verify that the invoice indicates your cost.
- Make sure that the invoice is dated prior to the date of service indicated on the claim.
- Check your catalog page to ensure that it contains the manufacturer's name and date of availability.
- Effective for dates of service prior to September 1, 2006, the acceptable catalog page, MSRP, must be dated prior to August 1, 2003.
- If you have DME that was not available prior to August 1, 2003:
– Indicate the date of availability in the Additional Claim Information field (Box 19) of the claim or handwrite the date on the catalog page or invoice.
– Indicate the statement, “new product” in the Additional Claim Information field (Box 19) of the claim or handwrite it on the catalog page or invoice.
– Ensure that you attach the manufacturer’s price list and/or order form or the catalog page that initially published the item being billed on the claim.
– Ensure that the Manufacturer’s Suggested Retail Price (MSRP) is on the catalog page.
- Effective for dates of service on or after September 1, 2006, the acceptable catalog page, MSRP, must be dated prior to June 1, 2006.
- If the manufacturer name or date is missing from the page, send a copy of the cover or back page of the catalog showing the effective date.
- It is acceptable to handwrite on the invoice or catalog page (for example, circling, drawing an arrow, underlining, or indicating the line number). Your claim will be denied if the invoice or catalog page is altered (for example, covering information or marking out information such as dealer cost or discounts).
- You may receive denial message 9098 if an item indicates zero payment on your invoice.
- DME labor charges are not separately payable when billed with new, purchased (modifier -NU) or rental (modifier -RR) equipment. Ensure that you are billing the correct code(s) and modifier(s).
- Labor charges are payable if the new item is a replacement part installed during a repair (modifiers -RP, -NU
or -NU, -RP) or the equipment is being repaired (modifier -RP).
- For dates of service on or after 01/01/06, the claim must contain the statement "the equipment is patient-owned" and the statement must include the specific procedure code and/or description of the equipment being repaired or serviced. This information can be indicated in the Additional Claim Information field (Box 19) of the claim or on an attachment.
- For dates of service prior to 01/01/06, the statement "the equipment is patient-owned" in the Additional Claim Information field (Box 19) of the claim or on an attachment is acceptable.
|Example:||Patient-owned E0601 or CPAP|
|Patient-owned K0001 or manual wheelchair|
|Patient-owned E1399 bariatric trapeze|
- Effective for dates of service prior to September 1, 2006, claims for non-wheelchair "By Report" procedure codes, must include the following:
– The manufacturer’s purchase invoice, indicating your cost, and the manufacturer’s catalog page, showing the retail price dated prior to August 1, 2003. If the item was not available prior to August 1, 2003, attach a manufacturer's purchase invoice and the catalog page that initially published the item and the MSRP.
– The item description.
– The manufacturer's name.
– The model number or catalog number.
– The reason a listed code was not used.
- Effective for dates of service on or after September 1, 2006, the manufacturer's catalog page must be dated prior to June 1, 2006.
If you have any questions, please call the Telephone Service Center (TSC) at 1-800-541-5555.
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