It’s April Fools’ Day & do I have a hoax for therapists wanting to bill Medicare in light of the Lymphedema Treatment Act (LTA). Seems simple, right? Read on…

Applicable Laws

There are several federal & state laws you need to be aware of to bill for compression (which falls under DME or durable medical equipment). A non-comprehensive list of these laws includes the supplier standards in the Code of Federal Regulations (CFR), anti-kickback laws & state DME regulations. It’s also going to cost a fair amount of money to start. The good news is, if you’re a therapist who already bills insurance as a provider, you can also bill for DME as a supplier within the same business. (You do need to consider, however, how taxonomy codes may impact reimbursement for commercial payors in such case.) If you want to bill for your own patients, setting up is simpler. If you want to bill for other people’s patients, it’s tricky & potentially more expensive. Let’s look at the first scenario in this blog.

Billing Insurance for Your Own Patients

If you have a therapy practice which bills insurance as a provider for lymphedema treatment, you’ll need to establish a DME part to your business to be a supplier. You should already have an office space (hopefully, that’s no less than 200 sq feet as required by federal supplier standards). So, the next step is to familiarize yourself with the 42^nd chapter of the Code of Federal Regulations. It says therapists in private practice can bill for their own patients & avoid some of the supplier standards that others must adhere to. Namely, you can avoid paying for a surety bond & having to keep the business open/staffed for a minimum of 30 hours/week. You still have to set up a separate land line that’s answered (no cell phones or call centers) & pay for accreditation, Medicare’s application fee & liability insurance (among other costs).

The second step is to contact your state’s DME licensing board to find out applicable laws. These laws may be under a different name such as “device distributors” for your purposes. Complete your state’s licensing paperwork & pay their fee.

Next, contact one of Medicare’s approved DME accreditation agencies. Medicare has a list of these agencies.¹ After ensuring you’re in compliance with their rules, complete their application & pay that fee. (Many suggest you also retain a consultant to help with all the required policy & procedures that must be implemented & on-hand during site visits.)

Fourth, once all laws & fees are paid, you’re ready to credential with insurance (if you want to be in-network). Call the credentialing line for each insurance company you’d like to contract with & specify that you’re seeking to be a DME supplier in-network. They’ll send you the necessary paperwork & fee schedule once you’re approved. (Be prepared: There may be some confusion with insurance credentialing staff if you’re already credentialed as a provider. Again, you’ll need to specify you want to credential as a DME supplier. You can hire a 3^rd party to assist with credentialing.) For Medicare, there’s an extra step. You’ll need to know your state’s local DMEPOS MAC (durable medical equipment, prosthetics, orthotics & supplies Medicare administrative contractor). These MACs have jurisdiction over specific regions in the United States. These jurisdictions are called A, B, C, & D. For example, Texas falls in jurisdiction C. The DMEPOS MAC for Texas is CGS Administrators (CGS Medicare).

Fifth, familiarize yourself with Medicare’s LTA billing requirements. If you’re already a provider billing insurance, you’ve got a leg up on understanding billing codes. For example, you know providers use CPT codes, but suppliers use HCPCS codes. You’ll also need to know about modifiers, when to use them & other billing requirements for the LTA.⁴  You can find out more about these requirements on your MACs site.

Conclusion

It’s important to note that just because you’re able to bill Medicare in your state doesn’t mean you can bill for DME for other states. We’ll cover that & billing DME for other people’s patients in the next post.

***UPDATE 06/11/24***

According to the National Provider Enrollment West (NPE West) division (granted to Palmetto GBA), therapists (billing for their own patients only) are no longer required to be accredited. But they must get a surety bond. (This is a change from the current rules.)² In an email, the administrator said, “Per CMS, lymphedema items are a separate benefit under SSA 1861(s)(2)(JJ).  They are not orthotics, prosthetics, and supplies mentioned in 42 CFR 424.57(d)(15)(i)(D)(3), and any OT/PT wanting to update the enrollment to furnish lymphedema items would not be “only billing for orthotics, prosthetics, and supplies”, and would no longer qualify for the surety bond exemption. CMS also contacted the HHS Office of General Counsel, which confirmed CMS’ determination.“

References
1 (DME accreditation list) https://www.cms.gov/files/document/dmepos-accreditation-organizations.pdf
2 (CFR 42) https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-424/subpart-D/section-424.57
3 (DMEPOS MACs) https://www.cms.gov/medicare/coding-billing/medicare-administrative-contractors-macs/who-are-macs
4 (modifiers) https://www.cgsmedicare.com/jc/pubs/news/2023/12/cope147943.html