Durable Medical Equipment Billing & Coding Support

HCPCS selection that matches the order and the item dispensed

Durable medical equipment claims succeed when the HCPCS code, quantity, rental or purchase indicator, and diagnosis narrative match the order and the clinical justification on file. Close-but-wrong HCPCS choices create denials that look like medical-necessity failures. MB Claims reviews charge data for code and modifier consistency and helps keep claim content aligned with supplier documentation. Upcoding or billing without required records is outside our approach. Supportable HCPCS selection is a clean-claim focus area because DME payers scrutinize item identity as closely as diagnosis coding. Quantity and unit-of-measure mismatches between the order and the claim line are escalated as their own defect pattern when they recur.

Documentation packets payers expect before they pay

Detailed written orders, face-to-face encounter evidence where required, diagnosis support, and product-specific worksheets often travel with the claim—or are demanded after adjudication. Incomplete packets stall payment even when the HCPCS line looks correct. Our process flags incomplete order elements when visible in the workflow and coordinates documentation requests during denial follow-up. We do not fabricate clinical justification. Practices that standardize packet completeness before dispensing reduce denial categories that are difficult to reverse after the beneficiary already has the equipment. Packet checklists differ by product family, so oxygen, mobility, and orthotic orders should not share a single vague readiness gate.

Proof of delivery as a payment gate, not a shipping afterthought

Proof of delivery is one of the most common DME denial and audit triggers. Missing beneficiary signatures, incomplete delivery dates, or mismatched quantities can sink otherwise clean claims. MB Claims treats proof-of-delivery completeness as a claim-readiness checkpoint whenever the documentation is available in the supplier workflow. When remittances cite delivery proof, we pursue corrected claims or appeals only if supportable records exist within deadlines. Reporting this denial category separately helps operations fix logistics rather than blaming coding. Delivery exceptions—porch drops, caregiver signatures, or partial shipments—should be documented at dispense time, not reconstructed weeks later during appeal.

Prior authorization and same-or-similar history checks

Medicare and commercial payers increasingly require prior authorization, same-or-similar equipment history, or specific coverage criteria for oxygen, CPAP, mobility devices, orthotics, and other DMEPOS categories. Dispensing before authorization clears creates high-balance risk. We help verify authorization status and relevant history signals before submission when data is accessible. Catching these gaps upstream reduces denials that are hard to reverse after delivery. Authorization denial categories are escalated to intake and sales operations with enough detail to change release-to-delivery behavior before equipment leaves the warehouse.

Rental versus purchase billing and continuing month logic

Rental versus purchase indicators, capped rental logic, and recurring monthly billing create DME-specific A/R patterns. Billing the wrong payment category or continuing rental claims after a purchase conversion generates avoidable denials. MB Claims reviews rental and purchase workflows in scope and documents next actions for recurring lines. Days-in-A/R reporting should separate first-month setup issues from ongoing rental follow-up so leaders do not misread a chronic setup defect as a month-end posting lag.

Supplier enrollment, PTAN, and location consistency

DME payment also fails when supplier enrollment, PTAN details, taxonomy, or practice location data do not match the claim. Medicare DMEPOS enrollment and commercial supplier contracting are separate tracks. We coordinate with credentialing workflows so billing does not assume participation that is not effective. Denial categories for enrollment are separated from documentation failures. Collection results still depend on coverage criteria and documentation completeness; they cannot be guaranteed. Multi-location suppliers should confirm which PTAN and address pair with each dispense before high-balance claims age.

Oxygen and CPAP compliance data payers request on audit

Respiratory DME claims often survive initial adjudication only to fail later when compliance downloads, titration evidence, or continued-need documentation are missing. Treating compliance data as an afterthought creates audit clawbacks and stalled refill billing. MB Claims flags when recurring respiratory claims lack available compliance or continued-need artifacts visible in the supplier workflow, and we pursue follow-up only with supportable records. We do not fabricate usage data. Reporting this denial and audit category separately helps clinical and logistics teams own refill readiness before the next month’s claim drops.

Orthotics and custom-fit documentation thresholds

Off-the-shelf, custom-fitted, and custom-fabricated orthotics carry different documentation and coding expectations. Billing a custom pathway without measurements, fitting notes, or qualifying diagnoses invites medical-necessity and coding denials. Our review checks whether HCPCS selection and available fitting documentation align before submission when those artifacts are in the workflow. Feedback stays tied to what the supplier actually recorded. When remittances concentrate on orthotic fitting detail, that pattern is escalated to dispensing operations so templates capture the threshold payers already enforce.