Orthotics & DME billing in podiatry is complex, filled with many pitfalls. One single mistake can result in a big loss for medical practices. Getting on top of durable medical equipment (DME) coding and billing ensures that all challenges to the revenue stream are minimized. In this blog, we will delve deep in how podiatry practices can improve their cash flow without compromising patient care. If you run a solo or group foot care facility, this blog will help you meet current compliance standards while also increasing earnings. Let’s get started.
Understanding Orthotics & DME in Podiatry
Durable medical equipment (DME) includes medical devices that are provided to patients for supplementary improvement in their quality of life. It includes wheelchairs, walkers, hospital beds, and orthotics. On the other hand, orthotics include external devices that can be worn on the foot or leg to support bone alignment. These medical devices play an important role in correcting any deformity and musculoskeletal pain. Common orthotic devices include shoe inserts, ankle-foot orthoses (AFOs), knee-ankle-foot orthoses (KAFOs), spinal braces, and custom-made supports.
Podiatry billing and coding are complex, requiring a team of experts having a thorough understanding of CPT and ICD-10 codes in podiatry. Since DME documentation requirements include prior authorization from insurers due to high-value claims, any type of error in billing or coding can become costly. Complete knowledge of the nuances of durable medical equipment (DME) billing is essential for smooth reimbursement flow.
Billing Basics: Orthotics & DME
Understanding the basics of medical billing and Insurance reimbursement for orthotics is essential for RCM teams. Here, we will discuss the basics of billing your patients for orthotic and DME devices and ensure you get paid for rendered services. For an error-free podiatry practice management, follow the steps mentioned below:
Coding Systems
In DME and orthotics coding, unique codes are used for rendered services. HCPCS codes are used for braces, boots, custom inserts, etc. Different types of CPT codes are used for procedures performed to improve the quality of life. ICD-10 codes are diagnostic codes for appropriately describing a patient’s condition in medical claims. Common podiatry billing errors can lead to partial or unpaid claims.
Documentation Requirements
Before billing a patient for an orthotic device, proper justification or medical necessity documentation is necessary. Physicians must provide a prescription detailing succinctly the complete diagnosis and device required for the patient. These documents are the backbone of compliance with Medicare’s DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) guidelines.
Insurance Coverage & Eligibility
In orthotics and DME billing, the importance of timely checking the insurance coverage, validity, and a patient’s eligibility is a mandatory step. Insurance coverage for DME and orthotic devices varies from payer to payer. The medical billing team must thoroughly check the insurance details, like co-pays, deductibles, and out-of-pocket costs, so that patients are informed before consultation.
Common DME Billing Challenges
Without overcoming common DME billing challenges, it is almost impossible for healthcare professionals to streamline the podiatry revenue cycle. Let’s discuss them one by one.
Insurance Complexity
Podiatry billing and coding differ from those used in medical and specialized care. The insurance coverage for various procedures, including routine nail/skin care (such as corns, calluses, and debridement), as well as orthotic inserts, walking boots, ankle braces, crutches, and specialized footwear, is quite complex. In case of non-compliance with the payer rules, DME practices can see frequent denials leading to revenue loss.
Prior Authorization Delays
Many items in durable medical equipment require pre-authorization from insurers. The lengthy process of waiting sometimes results in bypassing medical billing compliance guidelines, resulting in hard denials. The challenge arises when foot care physicians and their patients may have to wait 24-72 hours before the application for an orthotic device is approved, putting patient care at a pause.
Medical Necessity Denials
For foot care physicians, medical necessity must be clearly mentioned in clinical notes. In case of unclear or missing medical necessity justification, a claim may be denied. Typically, these claims are the ones that are of high-dollar value, urging prompt response from the billing team. Collecting documents from the patients and providers is a big hustle, delaying the orthotics reimbursement process.
Medicare Compliance Rules
Medicare regulations for reimbursements are becoming stricter every day. The ever-evolving guidelines change negatively affect the revenue cycle. A single non-compliance issue warrants risk of penalties, audits, and fraud investigations, leading to loss of revenue and reputation, all in one go. Regular audits are now a part of Medicare, Medicaid, and commercial insurers for DME and orthotics claims involving devices like diabetic shoes, inserts, and prosthetic legs, etc.
Future Trends in Podiatry Billing
The medical billing industry in the USA is diverting more towards technology and innovation. Podiatry and foot care institutions can proactively manage, understand, and forecast the impact on their revenue cycle. Let’s discuss the future implications for providers.
Automation / AI in Billing
Innovation in medical billing has impacted the revenue cycle of healthcare providers in many ways. AI-powered podiatry billing solutions are already in use and facilitate the process of error detection, claim submission, and payment posting. Foot care doctors relying on manual claim generation and submission can benefit immensely from the automation. AI-agents can submit more than 500 claims a day, helping fill the gap left by staff shortages.
Patient-Centric Billing Transparency
Medical billing practices are now becoming even more transparent thanks to the No Surprise Act, Emergency Medical Treatment and Active Labor Act, and Transparency in Coverage (TiC). In the future, healthcare practices will have to disclose all upfront treatment cost estimates and other additional charges before rendering medical care in non-emergency settings. Providers must adapt to such changes to facilitate patient care and improve their satisfaction level.
Conclusion
While podiatry practices are getting busier day by day, the challenges are also increasing for foot care providers. Understanding the basic billing techniques for orthotics and DME billing can help physicians get paid for rendered services. Moreover, keeping up with the changing regulatory framework and technology also future-proofs the revenue cycle for clinics.
If your podiatry clinic is suffering from revenue leakages, claim denials, and late submissions, outsourcing to Medheave medical billing company offers tailored RCM solutions. Our team improves claim accuracy, accurate coding, and timely submission, freeing you from billing duties and increasing clinical outcomes.
Frequently Asked Questions (FAQs)
What is the difference between orthotics and DME in billing?
Orthotics billing includes exclusively some of the support devices used by patients suffering from musculoskeletal disorders, bone deformities, etc. These devices are custom-made for patients thus are very expensive. Prior authorization is compulsory before billing a patient for such medical devices.
DME or durable medical equipment billing refers to reusable items like crutches, wheelchairs, hospital beds, and braces. Billing of both orthotics and DME requires prior authorization from the insurance company so they can be charged to a patient’s health plan.
When does Medicare cover orthotics and DME?
Medicare covers orthotics and DME billing if proper justification by the patient’s physician is given to payers. If the orthotics and DME medical devices are approved as medically necessary, insurance companies allow them to be billed; otherwise, such claims are denied.
What are the common reasons for claim denials in orthotics and DME billing?
In DME and orthotics billing, the majority of claims are denied due to:
- Missing or incomplete documentation of medical necessity.
- Incorrect coding or modifier use.
- Lack of a valid physician order
- Medical devices billed twice
- Orthotics and DME privileges are not included in the health plan, etc
