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Can a DME company use different diagnosis codes for orthotic splints?

Can a DME company use different diagnosis codes for orthotic splints?

Full question:

Can a DME company submit diagnosis to medicare for payment for orthotic splints by using diagnosis codes that medicare will pay for instead of the diagnosis submitted by therapists?

Category: Medicaid
Date: 04/07/2025
State: Florida

Answer:

Submitting a false diagnosis code to obtain payment from Medicare can be considered fraud. This practice, known as "code jamming," involves using incorrect diagnostic codes to mislead the government into approving a claim for payment.

This content is for informational purposes only and is not legal advice. Legal statutes mentioned reflect the law at the time the content was written and may no longer be current. Always verify the latest version of the law before relying on it.

FAQs

Is a splint considered DME?

Yes, a splint is generally considered durable medical equipment (DME) if it is prescribed by a healthcare provider for medical purposes. DME must be used in the home and can withstand repeated use. Splints are typically used to support, immobilize, or protect a body part, making them eligible for coverage under Medicare if they meet specific criteria.

How do I bill my DME claim to Medicare?

To bill a DME claim to Medicare, you need to complete the appropriate claim form, usually the CMS-1500 form, and include the necessary information such as patient details, diagnosis codes, and item specifics. Ensure that the DME is medically necessary and that you have the proper documentation from the prescribing physician. Submit the claim to the appropriate Medicare Administrative Contractor (MAC) for processing.

What are 5 criteria for Medicare's definition of DME?

Medicare defines DME based on five criteria: 1) It must be durable, meaning it can withstand repeated use. 2) It must be primarily used for a medical purpose. 3) It must be appropriate for use in the home. 4) It must be prescribed by a licensed healthcare provider. 5) It must not be primarily for comfort or convenience. Meeting these criteria is essential for Medicare coverage.

What DME does Medicare not cover?

Medicare does not cover certain items as DME, including but not limited to: 1) Equipment primarily for comfort, such as air conditioners or humidifiers. 2) Items that are not medically necessary, like exercise equipment. 3) Disposable supplies, such as bandages or gloves. 4) Equipment used for non-medical purposes. Always check with Medicare for specific coverage details.

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