The majority of discussions of DME Billing Service revolved around denials and reimbursement. DME claims are one of the most audited types of claims in the USA and any practice non-compliant with billing is not only at risk of denials. They face a risk of audit and overpayment claim, and in worst-case scenarios, they may not receive Medicare and Medicaid benefits. It is quite a new plane of financial exposure than an ordinary denial.
Why DME Claims Attract So Much Audit Attention
Durable medical equipment has been a high-fraud segment of healthcare claim types since time immemorial, which explains why CMS and the various private payer’s subject extra scrutiny to claims submitted by DME billing services than to most other types of claims. DME billing service submissions that fail to comply with those standards are not simply get denied. They get flagged. Claim patterns demonstrating missing documentation, mismatched HCPS codes, or missing authorization can act as a signal that results into a focused medical review that looks into months of billing history. The discovery of issues with that review results in the overpayment claims that are much more costly to settle than the initial claims would have been.
Documentation That Actually Holds Up in a DME Billing Service Review
A DME claim documentation package must contain a functional written order specifying the equipment, a certificate of medical necessity signed by the ordering provider and clinical notes, which explain the diagnosis of the patient and the functional limitation that makes the equipment necessary. All those aspects must be present, correct, and consistent with the others prior to a DME billing service claim is made. One of the most prevalent issues in the DME billing service audit is discrepancies between the written order and the delivered equipment. Even the slightest variance between the incurred delivery and the ordered item makes the claim prone.
HCPCS Code Accuracy in DME Billing Service
The codes used in Level II of HCPCS, which are related to durable medical equipment, are much more specific than most provider’s suspect. The right code of power wheelchair varies based on the weight capacity, drive system and the sitting arrangement of the wheelchair. The proper code of a continuous positive airway pressure device will be based on whether it is a fixed-pressure or auto-titrating unit. DME billing services teams not familiar with these differences use the wrong codes, which result in automatic denials upon audit or worse still, overpayment results after audit.
The importance of accuracy in modifiers is no less. A misplaced or wrong modifier on a claim made on a rental causes the calculation of the reimbursement not to account and results in payment rate of all claims in the rental process being at the wrong rate.
Behavioral Health Billing for Group Therapy and Intensive Outpatient Programs
Most considerations of Behavioral Health Billing concern the individual therapy session but collectively, group therapy services and intensive outpatient programs make most of the most intricate and economically important billing in behavioral health. The settings differ significantly in the coding rules, authorization requirements as well as documentation standards that are different to standard individual therapy billing. Attempts to treat these there meet with the same problems they encounter in an individual session; consistently they encounter problems.
Group Therapy Coding in Behavioral Health Billing
Group psychotherapy is billed on a patient per-session basis with a specific CPT code, different to that of individual therapy. The group therapy code varies as per the session length, as per timed individual therapy codes but not timed group therapy. The only difference is the change in documentation requirements. The progress note of each patient should reflect their personal involvement in the group and not a generalized observation of what the group talked about.
The payers that review behavioral health billing work on group therapy want to see individual documentation of each participant showing that the treatment is medically necessary to that particular patient and that they are making progress on his/her specific treatment goals. Even a single group note that describes the session without personal patient descriptions will not lead to the reimbursement of all patients in the group. This is a documentation issue rather than a coding issue but it gives out claim’s rejections the same.
IOP and PHP Coding in Behavioral Health Billing
These intensive outpatient programs and partial hospitalization programs are not only some of the highest valued claims in behavioral health billing, but also some of the most authorization-dependent claims. Commercial payers have a requirement that mandates concurrent review of patients in IOP and PHP levels of care, which requires creation of a regular schedule on which renewal of authorization must be fixed on a regular basis as the patient receives therapy.
The coding of both IOP and PHP services in behavioral health billing is coded per diem as specific revenue coding and procedure coding, which may vary based on the payer and the setting of care. Partial programs run in hospitals are coded differently as compared to a behavioral health facility run as a freestanding program. To get the following distinctions correct entails a behavioral health billing comprehensiveness that transcends typical outpatient therapy billing understanding.
