Compliance: Implement a pre-billing review

Q. What documentation should be in place before a DME claim is submitted?

A. A DME claim should not reach billing until the patient file already supports the item ordered, the patient’s eligibility and medical need, and the provider’s compliant delivery of service.

Start with the order. It should be complete, signed and specific enough for the item and accessories being billed. Then review the medical record to confirm it supports the diagnosis, coverage criteria and continued need. Many denials are not caused by the wrong code; they happen because the file does not clearly connect the code to the patient’s condition and payer requirements.

Next, confirm delivery documentation. The record should show what was delivered, when it was delivered, who acknowledged receipt, and what setup, safety or use instructions were reviewed. A signature alone is not enough if the file does not identify the item, accessories and patient/caregiver education provided.

Providers should also compare the file to accreditation expectations. Was the patient informed of rights and responsibilities? Were complaint procedures, equipment use and care, infection control, emergency planning or maintenance instructions addressed when applicable? These items may not always appear on a payer checklist, but they help prove consistent, responsible service.

The strongest providers use a simple, product-specific, payer-aware pre-billing review. It should help intake and billing catch missing signatures, outdated forms, incomplete medical records, missing education documentation and mismatched modifiers before the claim is submitted.

The patient file is the claim file – and the survey file. When providers build each record with both reimbursement and accreditation in mind, they reduce rework, strengthen audit response and create a more reliable path from referral to payment retention.

Cheryl Henninger, MHA, RRT, is the owner and senior consultant of TaGer Enterprises LLC. She can be reached at cherylh@tagerenterprises.com.