DME Terms
Define 'RUL'
Bonus: Provide an example
Reasonable Useful Lifetime (RUL) is the period after which Medicare will pay for the replacement of durable medical equipment (DME) that is lost, stolen, or irreparably damaged, typically ranging from 1 to 5 years for DME Items.
If payment was collected for a DME item, what must you do before hitting "finish order" in Empower?
Add the Self Pay code (and an ABN code if applicable)
Is it required to give each patient a copy of the POD? Why or Why not?
Yes - It is a part of our contractual agreement with the insurance companies that we must provide the patient a copy.
How much is a patient covered by insurance if CCHP authorized their brace?
100%
Is a Matt Strap billable to insurance?
No - Cash item $35
Define 'Date of Service'
Bonus: What is the difference between Date of Service and Date of Order?
Date of Service is the specific date when a patient physically takes possession of a DME item which is utilized for billing and insurance purposes.
Date of order is when the item is prescribed.
Explain the workflow for dispensing crutches.
Dispense in Empower and push to bill insurance regardless of the insurance or office location
(NU modifier, no laterality needed)
List 5 ways you can custom fit an LSO.
Cut/trim length of anterior panel
Heat mold anterior panel
Adjustment to inferior post. panel
Adjustment to superior post. panel
Trim string length
Angle belt down
Measure for sizing
Extension panel
Adjust belt to fit
Define a deductible
Bonus: A patient is prescribed a $1000 brace - They are covered 80% and have a 20% co-ins once their deductible has been met. The patient has $200 remaining on their deductible. How much will the patient be financially responsible for?
The amount a person is responsible for paying for services each year before the insurance company starts paying their portion of the costs.
Bonus - $400
What price is used when completing an ABN?
The cash rate of the item being dispensed
Define 'Same/Similar'
Bonus: Provide an Example
Same or similar is a Medicare policy preventing patients to receive the "same" or a "similar" item before the item's RUL.
Explain the workflow for a TLSO prescribed for a Medicare patient.
Send email to DME or directly notify Alexa/Erika
Check Same/Similar
Check medical necessity prior to dispensing
What should you tell every patient as you are preparing to get their signature after dispensing a brace?
*financial responsibility* Example: "Signing on this line allows us to bill your insurance for this item, however, if you have a remaining deductible or have a co-insurance, you may receive a bill for any remaining balance and will be held financially responsible.
How much does Medicare cover for a brace (assuming all medical necessity & requirements have been met) and how much is the patient responsible for?
Medicare covers 80%
If no secondary - Patient is responsible for 20%
If patient has a secondary insurance -remaining 20% will be billed, but if the patient has a deductible, they may receive a portion of the 20%
A patient is dispensed a lace up ankle brace - can they leave the office without the plastic hinge on the ankle brace? Why or Why not?
The plastic hinge on the brace is what makes the brace billable. If it is dispensed without it, the brace is no longer billable and we are not meeting compliance standards for insurance & Medicare.
Define a 'Split Code'
Bonus: Provide an example
A brace that can be either fitted to the patient off the shelf or custom fitted to the patient, each of which have their own associated HCPCs (LCodes).
If a CTU was approved for a Work Comp patient having surgery at SSP, when and where should the CTU be dispensed?
At SSP on the day of surgery
How should you answer the following question:
"Can I pay cash for this instead of going through my insurance?"
No, we are contractually obligated to bill your insurance, we are not able to accept cash for this item.
Define Co-Insurance
A percentage of the total costs each person is responsible for paying each year. Generally, once the deductible amount has been met, the insurance will pay a portion of the cost, and the patient is responsible for the rest.
How do you dispense a Michlitsch Special in Empower?
At preop dispense the tracker TO GO
Use a paper triplicate for the POKB to be delivered at SSP
Define 'Medical Necessity'
Bonus: How is medical necessity established?
Medical necessity for DME means the equipment is required to diagnose or treat a medical condition/injury and meets accepted medical criteria, which can differ between insurance companies and their policies.
The provider may establish medical necessity in their documentation of the office visit.
Explain the workflow of requesting time off.
Check the EB DME/Cast Outlook schedule
Notify Alexa/Erika
Add time off request to paycom
What are the components required to prove Custom Fit?
Time Spent
Tools Used
Specialized training of the Custom Fitter
What customizations were done
Why the customizations were necessary
Requires more than minimal self-adjustment
Define Out of Pocket Maximum
The maximum amount that is allowed to be paid by a patient for medical expenses each year.
Name a special test shown in the physical exam of a chart note that can demonstrate laxity in the knee.
Lachman
Anterior Drawer
Posterior Drawer
Valgus Stress
Varus Stress