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Wiki Dme and limits

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dosobill

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I have a DME that was denied because it exceeds the maximum allowed. Called and was told that the patient had received the same DME within the last three years. Has anyone else had this problem?? I am new to DME billing and just need a little advice. Thank you
 
Most insurance carriers have DME policies, Medicare contractors have LCDs for specific DMEs. Check the insurance company's DME policy and IF your provider did not previously issue the DME you may be able to appeal. However if your provider did previously give the patient the DME you may be out of luck since it is the office's responsibility to know what the policies are.
 
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Also, you need to check your Medicaid guidelines as well if the patient has Medicaid. What Medicare has as guidelines is not always the case with Medicaid and vica versa. Also, check for any NCDs that relate to the product. For example, Medicare has an NCD for Mobility Assistive Equipment (MAE) (280.3) that payers will use for why a denial was valid.

My advice, as Doreen stated, get to know the guidelines as most denials happen because of a guideline requirement that was not met verses a coding error.

Good Luck! Hope this helps.

Ida Landry, MBA, CPC
Director Keen Home Medical
Portland, OR
 
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