Phase III of Stark and DME

May 1, 2008

We have new durable medical equipment (DME) that we will be giving to our respiratory patients. We want to make sure that we can get reimbursed by Medicare for these items. The three products that may go out the door to patients are a flutter valve (code E0484), an Acapella flutter valve (also code E0484), and an aerochamber spacer device (code A4627). Is there anything special we need to know about billing for DME with Medicare or do we need to have the patients sign Advance Beneficiary Notices? We have just had to write items off in the past and don’t want to have to do that if at all possible.

Question: We have new durable medical equipment (DME) that we will be giving to our respiratory patients. We want to make sure that we can get reimbursed by Medicare for these items. The three products that may go out the door to patients are a flutter valve (code E0484), an Acapella flutter valve (also code E0484), and an aerochamber spacer device (code A4627).

Is there anything special we need to know about billing for DME with Medicare or do we need to have the patients sign Advance Beneficiary Notices? We have just had to write items off in the past and don’t want to have to do that if at all possible.

Answer: This response is from Sheri Poe Bernard, CPC, CPC-H, CPC-P, from the American Academy of Professional Coders:

Under the September 2007 Phase III rule of the Stark law, the circumstances under which physician practices may legally distribute DME is practically eliminated. Phase III reads, in part, “there are few, if any, situations in which a referring physician would personally furnish DME and supplies to a patient, because doing so would require that the physician himself or herself be enrolled in Medicare as a DME supplier and personally perform all of the duties of a supplier as set forth in the supplier standards.”

CMS further states that the referring physician would need to be enrolled as a Medicare DME supplier in order to act as one, and that the rules governing supply of DME are such it is unlikely a physician would meet the criteria.

What does that mean to your practice? Your days of supplying even the smallest DME items to Medicare patients may be over. You may need to find another effective way to ensure your Medicare patients have access to the supplies they need. And while not all payers have embraced all the varied pieces and parts of Stark law, many are adopting some portions as sound business practices.

It may be best these days to leave the business of DME to suppliers.