Navigating the constantly evolving landscape of Durable Medical Equipment (DME) billing can be challenging. As we have stepped into 2025, it’s important to stay abreast of the latest regulatory changes and trends in this field. This can help you ensure streamlined operations and optimal patient care.
In this blog, we guide you through the most recent updates in DME PA processes, fee schedules, code changes, and telehealth expansions to help you adapt and thrive in the dynamic DME billing environment.
1. Stay Ahead of 2025 DME Prior Authorization Trends
Here are some recent changes made in DME PA procedures to improve their accessibility and efficiency:
- Swift Prior Authorizations Are in Demand!
Starting January 1, 2025, CMS has capped the standard PA review timeframe at 7 days. The period for expedited cases remains 2 business days. To adapt, you must aim for faster but accurate submissions.
- No More PA for Specific DME Items!
From August 28, 2024, CMS suspended PA needs for the osteogenesis stimulators with HCPCS codes E0760, E0748, and E0747. This resolution addresses the confusion about these items’ compliance with the DME 3-year life requirement. Make sure you stay updated to handle eligible items properly.
- Electronic PA is Now Mandatory
The CMS has made it a must to implement electronic PA systems by January 1, 2026. The goal is to optimize and speed up prior authorizations. So, DME providers must embrace new technologies soon.
Time to adapt to these changes! But doing that within tight deadlines can be stressful, especially if PAs are handled in-house. So, consider outsourcing prior authorization to DME billing experts updated on these trends.
2. Note the Latest Alterations in DME Billing Fee Schedule
The CMS released the following adjustment updates to its consumer price indices for all urban consumers (CPI-U) for 2025. These will be applied to fee schedules of DMEPOS (durable medical equipment, prosthetics, orthotics, and supplies) items from January 1, 2025, and implemented from January 6, 2025.
- Fees for competitive bidding program (CBP) items in former Competitive Bidding Areas (CBAs) will go up by 2.9%.
- Fees for non-CBP items (like ostomy and urological supplies) are set to increase by 2.4%.
- Fees for CBP items in CPI-U (non-CBAs) shall rise by 3%.
For CBP items in rural areas, 50% will be unadjusted fee schedule from 2015 and 50% completely adjusted regional payment.
Some of the other important updates to DME billing codes are:
- Therapeutic Shoes: Modifications are being made to A5503 – A5507 and A5512 – A5514.
- Lymphedema Items: Fees of some of these items will surge by 3%.
- Oxygen Maintenance and Service (MS modifier): Their price will rise by 2.4% to yield an allowable of $87.82.
- Diabetic Testing Supplies: Updates to mail order diabetic testing supplies using the KL modifier.
- Repair/Non-Routine Service Code for DME Besides Oxygen: A 3% increase will happen associated with K0739.
You can expect that reimbursements will increase slightly while categories and items will differ. Focus on accurate DME billing and aligning claims with updated guidelines to include these fee changes and avoid denials or late reimbursements.
3. Learn About 2025 DME Code Changes
There have been some FY 2025 updates to HCPCS Level II codes. These are used to report for DMEPOS. These include changes include 63 removed codes, 56 modified code descriptors, and 169 new codes and have become effective from January 1, 2025.
Twelve E codes (E1803-E1829) have been added to the DME section of HCPCS. They represent dynamic adjustable elbow extension-only devices. These codes were introduced to fix an editing issue that was stopping providers from billing for both flexion and extension devices on the same claim. The parent code for every device has been revised to show the possible use of both devices. Besides, the existing codes for these devices have been amended so they read the same as the latest ones.
Make sure to remain up-to-date with these code revisions to avoid DME billing errors and enable correct reimbursements.
4. Leverage DME Telehealth Expansion by CMS in 2025
Here are the main changes in CMS’s telehealth expansion for durable medical equipment in 2025:
- Higher Coverage: CMS has permitted prescription of more types of DME and their monitoring via telehealth. This curtails the need for in-person visits.
- Expanded Provider Eligibility: A wider variety of healthcare providers can now recommend DME through telehealth. This would increase patient access and improve the revenue opportunities of DME suppliers.
- Augmented Compliance Requirements: CMS is implementing more stringent coding and documentation rules to avoid fraud and guarantee the medical necessity of telehealth-prescribed durable medical equipment.
As a result of these alterations, DME suppliers can benefit from higher approval rates for telehealth-based DME. However, some challenges are complex claim processing and the need for advanced DME billing and coding practices.
Therefore, work with expert DME billers specializing in accurate documentation, implementation of efficient coding and billing strategies and claim submission, and updated with compliance requirements for telehealth DME services.
The Wise Choice for DME Providers
This is a crucial question to DME suppliers: “Wouldn’t your in-house team be overwhelmed managing billing intricacies and these major changes?” The best solution is to outsource DME billing to a trusted revenue cycle management company. The company would house experts trained in end-to-end durable medical equipment RCM solutions from eligibility verification and prior authorizations to medical coding, charge posting, and claims processing. This move can ensure smoother operations, improved revenue, and better patient satisfaction.
