DME 101
What does “DME” stand for?
✅ What is Durable Medical Equipment?
What is a HCPCS code used for?
✅ To identify medical equipment in billing.
What is Medicare Part B known to cover?
✅ Durable medical equipment (DME)
What’s the first thing we check before billing?
✅ Patient insurance eligibility.
A denial means this happened to our claim.
It was not paid
What type of form is used to submit a DME claim?
✅ What is the CMS-1500?
What does “EOB” stand for?
✅ What is Explanation of Benefits?
What is a deductible?
✅ The amount a patient pays before insurance kicks in.
After a claim is sent, we wait for this.
✅ What is payment or response?
A denial for "no auth" means this was missing.
Prior authorization
DME is only covered when it’s used in this setting.
✅ What is the patient’s home?
What does CMN stand for and why do we need it?
✅ Certificate of Medical Necessity; it proves why the patient needs the item.
What is a payer?
✅ An insurance company that pays medical bills.
What system or tool helps us track billed claims?
✅ Billing software or AR dashboard.
If a claim is denied, what process lets us fight it?
An appeal
What makes a product “medically necessary”?
✅ It’s needed to treat a condition and ordered by a doctor.
What does “CO-45” mean on an EOB?
✅ It means the amount charged is above the allowed limit.
What’s the difference between a primary and secondary payer?
✅ Primary pays first; secondary pays what’s left (if covered)
80/20 rule
What do we call it when we match payments to claims?
✅ What is payment posting?
What’s one common reason a claim might be rejected before it even gets to the payer?
✅ Incorrect patient or policy info
(Will accept modifiers and documentation)
Name two types of documents that support medical necessity.
✅ What are a physician’s order and progress notes?
What does “modifiers” mean in billing?
Extra letters/numbers added to codes to give more info.
What’s the purpose of verifying insurance?
✅ To confirm coverage and avoid denials.
What is a remittance advice (RA) used for?
✅ It tells us what was paid or denied on a claim.
What can we do when a denial isn’t clear or looks incorrect?
✅ Call the payer or request an appeal review.