DME Glossary
Terminology for DME
Assignment - DME provider's agreement to accept Medicare's allowed charges as payment in full; requires provider to only bill beneficiary and/or coinsurance for the amount of unmet deductible
Beneficiary - Person eligible for benefits under the Medicare program
Certificate of Medical Necessity - Essential tool for determining coverage; form used requires documentation of patient's physiological need for specified DME POS services; required by Medicare or Third Party Payor to substantiate reason for payment of claim; contains patient ID, diagnosis, and reasons why the DME/HME item (e.g.; wheelchair) is medically necessary
Claim - Request for payment for benefits received or services rendered
CMN - See Certificate of Medical Necessity
CMS - Centers for Medicare and Medicaid Services (CMS), a federal agency; a division of the federal Department of Health and Human Services; formerly known as HCFA (Health Care Financing Administration)
CPT Code - Current Procedural/Procedure Terminology; code used by physician, provider, or supplier to describe the service rendered or provided to beneficiary
Data Elements - Required data (e.g.; bin number, processor control number, National Association of Boards of Pharmacy (NABP) number, patient last name, prescription number, and more) for completion of the electronically submitted claim record; requires software used for claim data entry capable of including all required data elements for successful claim submission
Diagnosis Code - Numerical classification descriptive of a disease, injury, surgical procedure, or cause of death; complete, accurate diagnosis code as listed in the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding system is required by federal law for each Medicare claim submitted for payment
Durable Medical Equipment (DME) - Special medical equipment used to aid handicapped individual's mobility and/or assist with specific therapy; sometimes used interchangeably with HME
DMERC - (Durable Medical Equipment Regional Carrier - old terminology; see DME MAC immediately below)
DME MAC - Durable Medical Equipment Medicare Administrative Contractor; Medicare Part B insurance carriers contracted by CMS to process claims for DME POS services in a specific jurisdiction (geographic area of the United States); processes claims for DME, HME, POS, PEN, and immunosuppressant drugs; use this link to visit the DME MAC Contact Information page on this website.
Electronic Data Interchange (EDI) - Electronic exchange of information using standard formats
Enteral Nutrition - Delivery of complete nutrition to a functioning gastrointestinal tract by means other than the oral route
HCFA - See CMS
HCPCS ('hix-pix') - CMS' Common Procedure Coding System; required by CMS when billing DME, HME, POS, PEN services and supplies; includes CPT codes to describe physicians' services and supplies
HME - See Durable Medical Equipment (DME)
ICD-9-CM Codes - See Diagnosis Code
Modifiers- Two-digit numeric or alpha code; used with a CPT code to indicate that a service or procedure has been altered (e.g., RR indicates item is rented; 'NU' indicates item is purchased)
NCPDP - National Council for Prescription Drug Programs Telecommunications Standard Format 3.2 or 4.0
NPI Number - National Provider Identifier number; this number replaced the UPIN number in May of 2007; use this link to visit the NPI resource page on this website.
NSF - National Standard Format; developed to facilitate electronic submission of claims and reduce quantity of paperwork; captures data required to establish medical necessity for DME, HME, POS, and PEN claims; includes electronic version of paper CMN and is accepted as full documentation
Non-Assignment - A claim for which the suppliers do not agree to accept Medicare's allowed charges; supplier bills beneficiary for all charges, and then submits claim as non-assigned; Medicare sends remittance to beneficiary
Orthotics - specialized medical equipment. appliances, or devices to support or supplement weakened or abnormal joints or limbs; Orthopedic appliances used to support, align, and prevent or correct deformities or to improve the function of movable parts of the body (e.g., a brace or splint)
Parenteral Nutrition - Feeding administration routes other than by way of the intestinal tract; e.g., intravenous
PEN - Parenteral and Enteral Nutrition
POS- Place of Service; location where patient uses provided services and items
Prescription - Written order from a physician for beneficiary's use of medications, DME, HME, POS, PEN
Procedure Code - See CPT Code
Prosthetics - Artificial body part; device designed to replace a missing part of the body or to make a part of the body work better (e.g., artificial eye or limb)
SADMERC - Statistical Analysis DMERC; the DMERC responsible for statistical analysis and distribution of data related to procedure codes, modifiers, pricing files, DME, HME, POS, PEN claims history; use this link to visit the SADMERC resource page on this website
UPIN - Unique Physician Identification Number; this number was replaced by the NPI Number in May of 2007.
