DME (DURABLE MEDICAL

EQUIPMENT)
ABOUT DME BILLING

• DME Billing is the Process of submitting and receiving payments for a claim from the
insurance company.
• DME is a therapeutic equipment that is prescribed by licensed physicians to patients who
suffer from certain medical condition or illness.
CPT CODES USED IN DME BILLING

 E0601 - Continuous positive airway pressure (CPAP)

device.

CPAP therapy is a common treatment for obstructive sleep

apnea. A CPAP machine uses a hose connected to a mask or
nosepiece to deliver constant and steady air pressure to help
you breathe while you sleep.

 E0562 - Humidifier, heated, used with positive airway

pressure (PAP) device.
Humidifier used with positive airway pressure
device as maintained by CMS falls under Humidifiers and
Nebulizers with Related Equipment
 E1390 - Oxygen Concentrator.
Oxygen concentrator, single delivery port,
capable of delivering 85 percent or greater oxygen
concentration at the prescribed flow rate.
 
 E0431 - Portable Gaseous Oxygen System.
Oxygen concentrator which is designed to be
portable, is capable of delivering 85% or greater oxygen
concentration, and is capable of operating on either AC or DC
(e.g., auto accessory outlet) power.

 
 E0470 - Respiratory Assist Device, Bi-level Pressure
Capability.
Respiratory assist device, bi-level pressure
capability, without backup rate feature, used with
noninvasive interface, e.g., nasal or facial mask
(intermittent assist device with continuous positive airway
pressure device).
 E0570 - Nebulizer with compression.
 
Its an electrically powered machine that turns
liquid medication into a mist so that it can be breathed
directly into the lungs through a face mask or mouthpiece.
 
 
 (K0001 – K0009) - Wheelchair.

Manual wheelchair bases (K0001, K0002, K0003,

K0004, K0005, K0006, K0007, K0008, and K0009) include
construction of any type material, including but not limited to,
titanium, carbon, or any other lightweight high strength
material.
US INSURANCE COMPANIES
 

 Medicare Insurance
 Medicaid Insurance
 Commercial Insurance
 
 
About Medicare Insurance

 Medicare is federal health insurance for people 65 or older, some

younger people with disabilities, people with End-Stage Renal Disease.

 A federal agency called the Centers for Medicare & Medicaid Services
runs Medicare. Because it’s a federal program, Medicare has set
standards for costs and coverage.
About Medicaid Insurance
 Medicaid provides health coverage to millions of Americans, including eligible low-
income adults, children, pregnant women, elderly adults and people with disabilities.
Medicaid is administered by states, according to federal requirements .

 The federal government has general rules that all state Medicaid programs must
follow, but each state runs its own program. This means eligibility requirements and
benefits can vary from state to state.
 
About Commercial Insurance
 Commercial health insurance is health insurance provided and administered by
nongovernmental entities. It can cover medical expenses and disability income for
the insured.

. Two of the most popular types of commercial health insurance plans are the
preferred provider organization (PPO) and health maintenance organization (HMO).
MOST COMMON DENIAL
REASONS.
 
 A1 – Claim Service/Denied.
 B9 – PT is in hospice / enrolled in hospice
 B13 – Previously Paid Claim
 11 – Diagnosis code is incorrect
 16 – Lack of adjudication
 18 – Duplicate Claim
 22 – Covered By Other Payer COB
 24 – Charges Covered Under capitation agreement or managed
care plan
 27 – Expenses after coverage termed
 29 – Timely Filing Limit
 45 – Exceeds Max Allowable
 50 – Deemed Not Medical Necessity
 96 – Non Covered Charges
 97 – Payment included in another services
 108 – Rent/Purchase Guidelines are not met.
 197 – Prior Authorization is required
 198 – Prior Authorization has been exceeded
 252 – Attachment is required