Wheelchairs, crutches, canes, compression sleeves, slings, electrodes and orthotics—these and other durable medical equipment (DME) are regularly prescribed by doctors to help injured workers manage their injuries. However, with a wide variety of makes and models available, many with an array of differing features, and all offered at multiple price points, how can payers ensure that their injured worker is getting the right product at the right price?
To provide some guidance, the Centers for Medicare and Medicaid Services (CMS) established the Healthcare Common Procedure Coding System (HCPCS) and many states have also enacted fee schedules. Many product manufacturers, distributors, retailers, and even some ancillary service providers, have also created catalogs and point-and-click systems in an effort to simplify the selection process.
Although these tools are helpful, contemporary claims management continues to rely heavily on human interpretation and interaction. With so many available options, continuous product innovation and advancements in medical care, ensuring the injured worker receives the right equipment at the right price can be a daunting task for even the most experienced claims professional. Here are some things to look for to maximize the effectiveness of DME bill review.
Modifiers influence fee schedule and, ultimately, the price paid for DME. Likely, you are familiar with some of the more common modifiers such as those indicating whether an item is a purchase, rental or in maintenance mode (NU/RR/MS respectively), and understand that a rental does not warrant the same reimbursement as a purchase. However, some state fee schedules also assign alternate allowable amounts based on lesser known modifiers, such as different technical and professional components, which comprise the entire service or the site at which the service was provided. The efficacy of DME bill review improves when you understand what the modifiers mean, when they are appropriate for use, and how they impact the ultimate cost.
Investigate Miscellaneous and Unspecified Codes
The miscellaneous and unspecified codes, E1399 or A9999, are long-recognized by claims professionals as an indicator or “red flag” that the bill warrants additional review. However, many other unspecified codes might go unnoticed, and therefore misused or abused due to lack of available fee schedule guidance. For example, code K0108 is for a “wheelchair component or accessory, not otherwise specified.” However, most wheelchair components, parts and accessories carry a specific code that could be more appropriate, at a lower allowable amount. Another example is A6549, a code for “gradient compression stocking/sleeve, not otherwise specified.” Here again, there are an array of compression codes that specify the gradient of pressure and length of the stocking. Knowing when a more specific code not only exists, but is more appropriate than a miscellaneous or unspecified code based on the circumstances of the claim and the injured worker’s needs, can greatly improve outcomes.
Evaluate Bundled Codes and Customization
Many providers feel that because a patient evaluation was completed, an item qualifies as “custom” and therefore warrants the use of a miscellaneous code such as E1399. This is not always the case so it is important for claims professionals to hold providers accountable for when and how they use the term to ensure accurate billing. For example, a power wheelchair with a basket or head lights is not “custom” but rather is a wheelchair with special options. When reviewing the bill, you should see a line item for the chair itself using the appropriate HCPCS for the base, with the additional components billed separately.
A good rule of thumb for determining if something is truly ‘custom’ and not a collection of components that should be coded separately is to ask if it was bundled by the manufacturer and whether or not the items are available for separate purchase. Many manufacturers publish order forms online that serve as a tool to identify which parts make up your ’custom‘ DME and what the retail price is for each item. There are however, circumstances when the manufacturer combines two or more items and the equipment becomes a totally new item, which then falls outside of the standard HCPCS definition. When in doubt, consult available resources and ask questions to confirm providers apply the most appropriate, cost-effective approach to billing.
Inspect HCPCS Quantities for Accuracy
Delving deeper into the codes themselves, it is important to be cognizant of the unit of measurement within the HCPCS definition. Some supply codes have very specific units of measurement which can result in HCPCS quantities that are not whole numbers and lead to mathematical errors or rounding. For example, code A4450 carries a unit of measurement of ‘per 18 square inches.’ This particular roll of tape is 2 inches by 5.4 yards equaling 388.8 square inches, giving it a HCPCS quantity of 21.6. Should you arrive at the wrong calculation, you could be paying for the wrong amount of product. Pay careful attention to quantities to ensure that both the amount of product supplied, and its cost, is just right.
Know Products beyond HCPCS Coding
Medications are assigned HCPCS codes along with a more specific national drug code (NDC) which includes brand name and product details. As with pharmaceuticals, there are many different providers and manufacturers of similar DME items. But, because HCPCS are not specific to brand, usually hundreds of different products fall under the same code, and DME is often wholesaled and subsequently relabeled. This can mask the true value of the item. Knowing the identity of the product manufacturer is important to be certain you’re not paying an exorbitant mark-up.
Achieving Better Outcomes
DME bill review requires deep expertise and fine attention to detail. It’s a complex business with numerous rules and thousands of codes in a constantly evolving marketplace. Perhaps the soundest advice is when in doubt, follow CMS Regulations, and consult your ancillary services provider, who likely has the breadth of experience and depth of expertise to help ensure timely, accurate and cost-effective DME bill review to achieve better outcomes.
Kelli Falter is manager of Provider Relations for Progressive Medical/PMSI, a company that works to control the growth of medical costs in workers’ compensation, liability and no fault insurance. Falter manages and develops the company’s ancillary provider network while providing internal support to better understand the program and its product offerings.