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🏠 Choice Medical Billing & Reimbursement Vault

Your internal hub for DME education, policy, and reference.
_Last updated: 11/26/2025

⚡ Quick Navigation

💬 Billing Tips

Day-to-day billing policy notes and practical training pieces.

🦽 Wheelchairs & Mobility

Capped rentals, upgrades, accessories, and modifier use.

Cushions

Upgrades

Hardware & Accessories

💨 PAP / Sleep

CPAP · BiPAP · ResMed Upgrades · Documentation

💉 Oxygen

Coverage, delivery rules, and rental cycle policies.

🧾 Checklists

Quick verification tools for documentation, setup, and billing accuracy.

✅ Use before claim submission or prior auth requests.

🏢 Insurance / Payer References

Allowables, modifiers, and plan-specific quirks.

🔍 References & Manuals

Essential Medicare & CGS reference material.

🧠 Myth Busters

Myth: "We have a Prior Authorization number, so the claim is guaranteed to pay."

Fact: A Prior Auth is NOT a guarantee of payment. It only confirms that the service is medically necessary based on the info provided at that time. If the patient loses coverage, or if the final delivery ticket doesn’t match the Auth, the claim can still be denied or recouped.

Myth: "If the doctor forgot to sign the notes, we can just ask them to sign it today and backdate it."

Fact: NEVER backdate. Medicare considers this fraud. If a signature is missing, the doctor must sign with the current date and the text should clearly state it is a “Late Entry” or “Addendum” to the previous record.

Myth: "The KX modifier just tells Medicare we have the paperwork."

Fact: The KX modifier is a legal attestation. By applying it, you are swearing to Medicare that every single requirement (face-to-face, specific LCD criteria, SWO) is physically in the file. If you use KX and are missing one piece of paper during an audit, it is an automatic fail.

Myth: "We can put 'Lifetime Need' on the CMN to avoid getting new notes."

Fact: “Lifetime” refers to the patient’s clinical condition, not the paperwork validity. Most orders (SWO) are good for the “length of need,” but many payers (and Medicare) require recertification or new clinicals annually or if there is a break in service/billing (like the “Missed Capped Rental” rule).

Myth: "The patient needs a wheelchair to get to dialysis/church, so Medicare covers it."

Fact: Medicare’s “Mobility Deficit” rule is strict: the patient must need the device to function inside the home. If they can walk around their living room but not to the mailbox, Medicare will deny the claim. The need must be “within the four walls.”

Myth: "We can put CPAP supplies on 'Auto-Ship' so the patient never runs out."

Fact: Medicare strictly prohibits automatic shipment of supplies (Contact before delivery). You must have a documented refill request from the patient confirming they actually need the supplies and that their current supply is nearly exhausted. “Auto-ship” is a magnet for audits.

Myth: "The 36-month Oxygen cap resets if the patient switches suppliers."

Fact: The 36-month clock stays with the patient, not the supplier. If a patient comes to us at Month 30, we only get paid for 6 months of rental before we are obligated to service the equipment for free (for the remaining 2 years of useful life). Always check the Common Working File (CWF)!