How to ensure accurate billing for durable medical equipment orders

This article, consisting of answers to questions posed by Medical Economics readers, will help clear up confusion about durable medical equipment (DME) orders and ensure accurate billing. Plus, we tackle a question on the mind of many practices: The delay of the International Classification of Diseases-10th Revision (ICD-10).

Q: Regarding your article pertaining to DME orders, is it necessary to make a copy of the patient visit documenting the need for the equipment and supply this copy of the patient’s visit to the DME provider along with the signed order?

A: The patient’s medical record documentation does not have to be routinely sent to the supplier or to the Durable Medical Equipment Medicare Administrative Contractor (DME MACs), DME Priority Care Solutions (PSCs) or Zoned Program Integrity Contractors (ZPICs), according to the Medicare Program Integrity Manual, Chapter 5 (Items and Services Having Special DME Review Considerations), Section 5.5 (Documentation in the Patient’s Medical Record)

However, these entities may request this information in selected cases.

Q: Our DME suppliers are saying that only the physician can sign the prescription for DME equipment. If the physician has seen the patient and addressed the issues in a note that pertain to the DME being ordered, can the nurse practitioner (NP) or physician assistant (PA) sign the Rx?

A: Section 5.2.3.2 of the Medicare Program Integrity Manual states, “The physician must document that the physician, PA, NP, or clinical nurse specialist (CNS) has had a face-to-face encounter with the beneficiary within six (6) months prior to completing the detailed written order.” 

It goes on to state that, when a DME supply is ordered by a PA, NP or CNS, an MD or DO needs to verify that a face-to-face encounter occurred by signing or co-signing the pertinent portion of the progress note that indicates there was a face-to-face encounter. 

(Note: A single confirming signature and date is sufficient in a situation where there are several pertinent portions of the medical record.)

An NP or CNS may give the dispensing order and sign the detailed written order in the following situations:

• they are treating the beneficiary for the condition for which the item is needed;

• they are practicing independently of a physician;

• they bill Medicare for other covered services using their own provider number; and

• they are permitted to do all of the above in the state in which services are rendered.

PAs may provide the dispensing order and write and sign the detailed written order if they satisfy all the following requirements:

• they meet the definition of physician assistant found in 1861(aa)(5)(A) of the Act;

• they are treating the beneficiary for the condition for which the item is needed;

• they are practicing under the supervision of an MD or DO;

• they have their own NPI; and

• they are permitted to perform services in accordance with state law.

Next: DME claim denials

Q: We have received a couple of denials from Medicare we can’t figure out. They say the referring provider can’t order or refer. What does this mean? Can we bill the patient?

A: According to MLN Matters® SE1305, beginning January 6, 2014, the Centers for Medicare and Medicaid Services (CMS) turned on the Phase 2 ordering/referring denial edits. 

This means that Medicare will deny Durable Medical Equipment, Prosthetic, Orthotic, and Supplies (DMEPOS) claims if the ordering/referring physician is not identified, not enrolled in Provider Enrollment, Chain, and Ownership System (PECOS), or not of a specialty type that may order/refer the service/item being billed.

Below are the American National Standards Institute (ANSI) denials that will be listed on your Remittance Advice if the ordering/referring provider’s National Provider Identifier (NPI) reported on the claim does not pass the edits.

CO-183: The Referring Provider is not eligible to refer the service billed.

N574 - Our records indicate the ordering/referring provider is of a type/specialty that cannot order or refer. Please verify the claim ordering/referring provider information is accurate or contact the ordering/referring provider.

CO-16: Claim/service lacks information that is needed for adjudication.

N264 - Missing/incomplete/invalid ordering provider name.

N265 - Missing/incomplete/invalid ordering provider primary identifier.

N575 - Mismatch between the submitted ordering/referring provider name and records.

Make sure that the qualifier in the electronic claim 2420E NM102 loop is 1 (a person). Organizations (qualifier two) cannot order/refer.

In response to your second question, SE1305 reads, “Claims from billing providers and suppliers that are denied because they failed the ordering/referring edit will not expose a Medicare beneficiary to liability. Therefore, an Advance Beneficiary Notice (ABN) is not appropriate in this situation.” 

Q: How should practices proceed now that ICD-10 has been delayed?

A: As I review provider documentation, I believe we need to stay diligent with our provider support and ICD-10 education.  The specificity needed for ICD-10 coding is what we’ve been requesting from our providers for years under ICD-9 coding.  The principles are the same that apply to current documentation and support quality, severity, and risk. 

Gap analyses reveal that unspecified coding is being used between 38% and 64% of the time, depending on the specialty. This gives a clear indication of why payers believe that our patients aren’t that sick and don’t want to increase their fee schedules. Using an unspecified code such as 250.00 (Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled) does not give the detail to support the severity of the patient’s condition.

Continuing to improve documentation today will help providers support the quality, severity, and risk involved with patient care, resulting in higher levels of evaluation and management services and quality dollars.

Answers to readers' questions were provided by Renee Dowling, a billing and coding consultant with VEI Consulting Services in Indianapolis, Indiana. Send your billing and coding questions to medec@advanstar.com.