Durable Medical Equipment (DME) Dispensing Explained


Are you currently dispensing Durable Medical Equipment (DME), or are you considering dispensing Durable Medical Equipment? When a patient is in pain, a common response is to reach for pain medication. While these pharmaceuticals may be useful and necessary, DME can be a great adjunct or alternative to help your patients. DME aids in the reduction of patient pain and recovery, helping in numerous ways such as offloading painful joints and restricting the motion of painful ligaments. DME can be prescribed in your clinic at the patient’s initial visit, and further implemented throughout their treatment plan. DME is very versatile and can greatly benefit your patients while increasing clinical revenues and so therefore begs the question: when can a clinic provide a piece of DME to their patient? With everything revolving around medical necessity, this question is one that many clinics do not understand. What is Medical Necessity and how will this allow me to implement DME into my practice?

Cigna.com states, “Medical Necessity shall mean health care services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms…” Fortunately, Medicare has LCDs publicly accessible, allowing a practitioner to see when a condition meets medical justification for a particular brace. If your patient has that condition, then you can look to fit them. Even as your patient nears the end of their treatment plan, they will continue to need motion restriction and support to prevent damage and aid in the patient’s recovery as they return back to work and other day-to-day activities. Without bracing, your patient greatly risks the possibility of re-injury. Bracing with DME could be crucial, therefore it is important for a physician to understand the versatility.
When and how can a brace be worn? While this depends on the judgement of the prescribing physician, we have seen bracing commonly prescribed postsurgically, proceeding a non-surgical, traumatic injury, during the rehabilitation process, during strenuous tasks such as hiking or working, or anytime the patient experiences pain. Depending on the patient’s condition, you may even prescribe it to be worn regularly for any and all activities day-to-day. There are several mechanisms of action involved with bracing and each brace has its own specific purpose designed to aid in the condition that it is needed for. With these mechanisms we can restrict motion by using compression and force, offload a knee with a varus/valgus hinge, or restrict range of motion. For example, a back brace would be provided to your patient per Medicare, “to reduce pain by restricting mobility of the trunk, to facilitate healing following an injury to the spine or related soft tissues, to facilitate healing following a surgical procedure on the spine or related soft tissue, or to otherwise support weak spinal muscles and/or a deformed spine.” If you believe that your patient meets any of this criteria, Medicare states that you have the justification to give them the brace. DME is not only a simple, beneficial way to assist your patients, but DME can also greatly assist your revenue stream.

The final advantage of DME is revenue benefit. Implementing bracing protocols in your clinic and educating your staff on billing these braces appropriately will drastically increase your revenue. For example, a knee brace for treatment of osteoarthritis (coded L1851) will reimburse around $850 – $900. Think briefly about how many patients come into your clinic with knee osteoarthritis. What about back pain? A lumbosacral brace (coded L0650) will reimburse approximately $1100 to $1350 per brace! Providing the patient with a properly fitted brace is a perfect opportunity to quickly and effectively relieve their pain while they continue their therapy.

Please take a moment once again to think back on Medicare’s previous quotation and what they consider medically justified for back pain, “to restrict motion of the trunk to reduce pain”. How many of your patients fit that scenario? Your patients will need DME for support and pain relief, whether it may be supplemental or adopted fully into your treatment plan. A clinic with ten to fifteen new patients experiencing knee pain alone could generate well over $9,000 additional revenue per month. That same clinic with ten to fifteen patients having back pain can generate over $13,000 additional revenue every month. Within a year’s time, this will amount to bringing in around $250,000 additional revenue just by implementing DME. Sounds good, right? If you have yet to be convinced, here are the top five signs that your clinic needs a stronger DME protocol.

How many patients do you see in pain? How many of them receive a brace? If that number is less than 60%-80% of your patients then that is a sign that your clinic needs a stronger DME protocol. Second, if your clinic provides only one type of DME (such as a back brace) then an expansion of your portfolio may need implemented. Third, if you are receiving a high number of denials, then there is a medical necessity and charting problem. Forth, if your clinic does not provide a certain piece of DME (such as an Osteo Knee Brace) because of the lack of understanding or confusion behind a specific DME, then a stronger DME protocol through training would be necessary. Finally, DME is truly not difficult to implement, if you are running into issues with this then that is likely a clinical workflow issue, which we can also direct you with. These five signs are most easily recognizable and can help evaluate if your clinic is meeting a strong DME protocol; however, once this actualization takes place there a few common mistakes to prevent and watch for.

The top three mistakes of DME program implementation include: understanding, choosing the inventory, and over-paying for it. Not fully understanding medical necessity and documentation when dabbling with DME is a huge mistake and is critical for a solid claim. Buying the wrong DME product is also a common mistake when implementing DME. There are many products to choose from and that can make it very difficult to know what is best. Fortunately, we will walk you through all of your options so that you purchase the correct product for the correct condition because if the patients do not like the DME or it does not help them, then they will not keep it. The third most common mistake when implementing DME is overpaying. DME can be extremely profitable, but you have to watch what you are paying considering the issue of declining reimbursement at hand. It is easy to over pay!

To surmise, DME will not only help your patients with pain management during treatment, but also will increase your revenue stream greatly. There are a handful of common signs that your clinic should watch for if you are unsure of the strength of your DME protocol. With implementation there are common mistakes to watch for, but by providing this information up front and educating you all I am confident that you will seek to implement DME into your clinics!

About The Author

Brandon Dilbeck
Spectrum Medical