DME in a sleep center

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DME in a sleep center

Postby mohdaw83 » Thu Mar 05, 2015 8:58 am

We are starting to provide DME in the sleep center

For billing gurus, when do you (or do you not) use the RR modifier when billing for CPAP machines through private insurances that rents the machine for a number of months??

Also, we are considering providing DME for our Medicare patients by being a sub contractor to one of the local DME companies that won the Medicare bidding contract.
Anyone doing that? Any insights? Our understanding is that we provide the machine and the DME company pays us a fee for providing the service, but they handle the billing.

Thank you :)
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Re: DME in a sleep center

Postby mohdaw83 » Thu Mar 05, 2015 9:07 am

We are trying to keep all our patients under one roof, so we have better control over compliance.
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Re: DME in a sleep center

Postby somnonaut » Thu Mar 05, 2015 1:41 pm

A DME in your lab sounds sketchy at best. I doubt CMS would look highly at providing DME out of your facility when they do not let DME provide HST at all. CMS would be all over that setup.
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Re: DME in a sleep center

Postby tiredjohnny1 » Sat Mar 07, 2015 12:09 am

Which modifier to use depends on many factors. One factor is insurance requirements such as Medicare/Commercial/capped plan. You might also need some additional modifiers. If you're asking basic billing questions like this, you probably shouldn't attempt to provide DME. The billing issue is the least complicated issue. Federal and state regulatory licensing and compliance are typically the most daunting. (For example, if an 'act of god' or terrorism catastrophe were to happen, who is immediately replacing all the machines already in use by patients in their homes, since they are considered respiratory devices necessary for sustaining life? Do you have that inventory immediately available?, etc.) I strongly caution a sleep lab to only provide DME after lengthy legal consultation and contracting by the health care attorney.

That being said, some national DME companies will engage local accredited sleep labs in a professional services agreement, PSA. Basically that means that the DME company is the PAP provider, but the lab provides the professional services, the staff member to dispense the equipment and educate the patient. The companies make sure that all the Federal/State antikickback safe harbors are in place so that no laws are being broken. Its really a great arrangement for the patient/lab/DME, as all benefit.

Somno, you are right. If the lab is physician-owned and the lab provides the equipment to a Medicare patient, that is a clear Stark violation.
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Re: DME in a sleep center

Postby burchab1 » Wed Jun 10, 2015 4:56 pm

As far as Medicare I would stay away. As far as the RR modifier, we always call the insurance company and talk to a representitive and ask about out of pocket expense and they will tell you if it needs to be a rental or if prior authorization is needed. And I have been doing DME in sleep labs for a number of years and it is what keeps us viable. Also go ahead and start the accreditation process with the AASM for the DME side.
Lastly did you get a DME contract with the insurances or are you using the sleep center? There is a difference especially when it comes to BiLevel and ASV.
Good luck and feel free to email me with any questions.
rburcham@sandhillsneurologists.com
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Re: DME in a sleep center

Postby Margaret Townsend » Thu Aug 06, 2015 6:44 pm

Good Afternoon;

I think the best person to handle DME for sleep is the sleep center provided they have the experience. THEY know the patient, the patient tolerance, mask fitting, etc.. If you are the subcontractor to a DME company, you do all the work and they make all the money. Think about it. YOU set the units, explain the usage to the patients, cleaning, etc.., then you measure and show the patient different masks and you and the patient decide on the best one for them, you provide the filters, tubing, etc..

The DME company offers you a fee for the set up (what 100.00 if that) and they do the billing, I'm sure they are charging the maximum for the units (1500.00 - 2200.00) depending on the insurance. Then they replace or supply you with additional units so they can make more money on the units you put out there, Not a very good business decision. Get your own DME providership and keep the money in house.

As for billing, the modifier RR identifies the unit as a rental for the initial first month and KX identifying that documentation is available to support medical necessity. Then on the second and third month rental modifiers to be used are RR, KI and KX. Fourth to 13th month RR, KJ and KX. The KX does not mean that documentation has to be sent. This only means that there is documentation on file if required that supports the issuing of the machine.

Of course all interfacing you use the A code with NI and KX. This identifies new equipment. Interfacing can not be rented.

If you would like more information on setting up your own DME for the sleep center, I am available for hire,
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Re: DME in a sleep center

Postby mohdaw83 » Thu Aug 27, 2015 10:12 am

Thank you all for your input. It's greatly appreciated.
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