Sunday, August 28, 2016

Provider Billing for Prosthetic and Orthotic Devices


These items consist of all prosthetic and orthotic devices excluding parenteral/enteral nutritional supplies and equipment and intraocular lenses.


Prosthetics and orthotic devices are included in the Part A PPS rate unless specified as being outside the rate. For SNFs, customized prosthetic devices that are not included in the Part A PPS rate and which may be billed separately are identified in the SNF HCPCS HELP file. Click here to access the file electronically. The file is updated as CMS determines appropriate. It describes HCPCS codes for services included in Part A consolidated billing, the services separately billable by the SNF or supplier under Part B for Part A and/or Part B inpatients, and services that may be billed by a supplier but not by SNF. If these latter services are billed by the SNF, no additional payment will be made. If the SNF or hospital wants also to be a supplier, they must enroll with National Supplier Clearinghouse and bill the DMERC. However, the DMERC will not separately pay for items of DME provided to a beneficiary in a Part A SNF stay.

Those items or services that are considered outside the PPS rate may be billed by the supplier in the case of a SNF or hospital to the FI, or if furnished by a qualified outside entity, that entity may bill its normal contractor.

The SNFs, hospitals, or other entities that furnish prosthetic and/or orthotic devices to their patients for whom Part A benefits are not payable (i.e., no Part A entitlement or benefits exhausted) may bill for such items, assuming other billing requirements are met.
NOTE: Items such as catheters and ostomy supplies are excluded from the fee schedule when billed by HHAs for patients under a plan of care. In this situation, HHAs bill for these items as supplies under revenue code 0270. Effective with items furnished on or after January 1, 1994, the fee schedules for ostomy, tracheostomy, and urological supplies are calculated using the same method
used to calculate the purchase fee schedules for inexpensive or other routinely purchased DME.

HCPCS codes A4214, A4310 through A4330, A4338 through A4359, and A5102 through A5114 are excluded from the fee schedule when billed by hospitals along with an ASC service. Hospitals bill for these items as supplies, under revenue code 0272. In addition, HCPCS codes A5119 through A5131 are excluded from the fee schedule unless they are submitted with ostomy related ASC procedure codes 44340 through 44346, 44380, 44382, 44388 through 44392, or 50953 through 50961.

In all other circumstances, including HHAs billing for patients not under a plan of care, SNFs, CORFs, OPTs, and hospitals bill these items as prosthetics and orthotics under code 0274, along with the relevant HCPCS code.

DMERCs only – For all states that have licensure/certification requirements for provision of prosthetics and/or orthotics, DMERCs shall process claims for Prosthetics and Certain Custom-Fabricated Orthotics only when the following specialty codes are forwarded to the DMERCs from the NSC. The specialty codes are:

• Medical Supply Company with Orthotics Personnel – Specialty Code 51;

• Medical Supply Company with Prosthetics Personnel – Specialty Code 52;

• Medical Supply Company with Orthotics and Prosthetics Personnel – Specialty Code 53;

• Orthotics Personnel – Specialty Code 55;

• Prosthetics Personnel – Specialty Code 56;

• Orthotics Personnel, Prosthetics Personnel and Pedorthists – Specialty Code 57,

• Physical Therapist – Specialty Code 65;

• Occupational Therapist – Specialty Code 67;

• Ocularist – Specialty Code B5; and

• All Physician Specialty Code listed in this manual [IOM] Chapter 26, §10.8.2

These specialties shall be licensed or certified by the state when applicable. These specialties shall bill for Medicare services when State law permits such entity to furnish a prosthetic or orthotic.

Claims billed by other specialty codes for prosthetics and certain custom-fabricated orthotics shall be denied.

Thursday, August 25, 2016

Medicare Summary Notice (MSN) and Remittance Advice (RA)


MSN 36.01:

Our records show that you were informed in writing, before receiving the service that Medicare would not pay. You are liable for this charge. If you do not agree with this statement, you may ask for a review. ASC X12 835, remittance advice remark code M38

MSN 36.02:

It appears that you did not know that we would not pay for this service so you are not liable. Do not pay your provider for this service. If you have paid your provider for this service, you should submit to this office three things 1) A copy of this notice, 2) Your provider’s bill, and 3) A receipt or proof that you have paid the bill. You must file your written request for payment within 6 months of the date of this notice. Future services of this type provided to you will be your responsibility. ASC X12 835 remittance advice remark code M25)

MSN 8.51:
You signed an Advanced Beneficiary Notice (ABN). You are responsible for the difference between the upgrade amount and the Medicare payment.

Use the following messages when denying claims due to invalid ABN upgrade information:

MSN 8.53:
This item or service was denied because the upgrade information was invalid.

MRN N108:
This item/service was denied because the upgrade information was invalid.
120.1 - Providing Upgrades of DMEPOS Without Any Extra Charge


Definitions of Modifiers that May be Associated with ABNs

GA - Waiver of Liability (expected to be denied as not reasonable and necessary, ABN on file)

GZ - Item or Service not Reasonable and Necessary (expected to be denied as not reasonable and necessary, no ABN on file)

GK - Reasonable and necessary item/service associated with GA or GZ modifier

Monday, August 22, 2016

General Instructions for the Use of ABNs for Upgrading DMEPOS Items


1. An upgrade may be from one item to another within a single Heath Insurance Common Procedure Coding System (HCPCS) code, or may be from one HCPCS code to another. When an upgrade is within a single code the upgraded item must include features that exceed the official code descriptor for that item.

2. The upgrade must be within the range of items or services that are medically appropriate for the beneficiary’s medical condition and the purpose of the physician’s order. ABNs may not be used to substitute a different item or service that is not medically appropriate for the beneficiary’s medical condition for the original item or service. The upgraded item must still meet the intended medical purpose of the item the physician ordered.

3. Use of an ABN to furnish an upgraded item or service, with the beneficiary being personally responsible for the difference between the costs of the standard and upgraded item or service, does not change coverage or payment rules, statutory provisions, or manual instructions for the particular benefit involved.

4. In cases where the DME MACs would make payment for the item the physician ordered on a rental basis, the supplier must furnish the upgrade on a rental basis.

5. A supplier furnishing an upgrade and using an ABN must submit a claim and include information on the claim that identifies the upgrade features. Suppliers must submit a claim for upgraded items and services using the GA modifier on the upgraded line item to indicate that the beneficiary signed an ABN. Suppliers must list upgrade features using the ASC X12 837 professional claim format or on the paper Form CMS-1500 in Item 19 or as an attachment to the claim for paper claims.

6. Denials should be based on medical necessity.

Saturday, August 20, 2016

DME MACs Only - Appeals of Duplicate Claims - Reasone code N111


The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) must afford appeal rights for the initial determination of an item or service only, unless the supplier is appealing whether or not the denied item is actually a duplicate. If a claim is denied as a duplicate, the DME MACs must not afford appeal rights based on coverage, medical necessity, pricing, or any basis on which the supplier can otherwise appeal. The DME MAC may only afford appeal rights on claims denied as duplicates if the supplier is appealing because the claim is not, in fact, a duplicate. If a supplier appeals a denied duplicate claim on the basis that the claim is not, in fact a duplicate, the DME MAC shall adjudicate the claim in accordance with all other Medicare rules and regulations.


The DME MACs must use the following Medicare Summary Notice (MSN) and ASC X12 835 remittance messages when denying duplicate claims:

MSN 7.3 – This service/item is a duplicate of a previously processed service. No appeal rights are attached to the denial of this service except for the issue as to whether the service is a duplicate. Disregard the appeals information on this notice unless you are appealing whether the service is a duplicate. Spanish – Este servicio/artículo es un duplicado de otro servicio procesado previamente. No tiene derechos de apelación de este servicio, excepto si cuestiona que este servicio es un duplicado. Haga casa omiso a la información sobre apelaciones en esta notification, en relación a sus derechos de apelación, a menos que este apelando si el servicio fue duplicado.

Claim adjustment reason code 18:- Duplicate claim/service

Remittance advice remark code N111 – This service was included in a claim that was previously billed and adjudicated. No appeal rights attached except with regard to whether the service/item is a duplicate.

Thursday, August 18, 2016

Facility Responsibilities During the Transition Period


1. A facility remains responsible for furnishing medically necessary items to a beneficiary for the full duration of a beneficiary's stay. The DRG and PPS rates cover such items.

2. A facility may not delay furnishing a medically necessary item for the beneficiary's use or treatment while the beneficiary is in the facility. A facility may not prematurely remove a medically necessary item from the beneficiary's use or treatment on the basis that a supplier delivered a similar or identical item to the beneficiary for the purpose of fitting or training.

3. A facility may not, through a stratagem of relying upon a supplier to furnish such items, improperly shift its costs for furnishing medically necessary items to a beneficiary who is a resident in the facility to Medicare Part B.

Nevertheless, beginning two days before the beneficiary's discharge, a facility may take reasonable actions to permit a supplier to fit or train the beneficiary with the medically necessary item that is for subsequent use in the beneficiary's home. These actions may include the substitution of the supplier-furnished item, in whole or in part, for the facility-furnished item during the beneficiary's last two inpatient days provided the substitution is both reasonable and necessary for fitting or training and the item is intended for subsequent use at the beneficiary's home.

4. For prosthetic and orthotic (P&O) items, the above restrictions apply to residents in a covered Part A stay. For DME, the above restrictions apply in a covered Part A or a Part B stay.

Monday, August 15, 2016

Date of Service for Pre-Discharge Delivery of DMEPOS


For DMEPOS, the general rule is that the date of service is equal to the date of delivery. However pre-discharge delivery of items intended for use upon discharge are considered provided on the date of discharge. The following three scenarios demonstrate both the latter rule (when the date of service is the date of discharge) and related exceptions.\

1. If the supplier leaves the item with the beneficiary two days prior to the date of discharge, and if the supplier, as a practical matter, need do nothing further to effect the delivery of the item to the beneficiary's home (because the beneficiary or a caregiver takes it home), then the date of discharge is deemed to be the date of delivery of the item. Such date must be the date of service for purposes of claims submission. (This is not an exception to the general DMEPOS rule that the date of service must be the date of delivery. Rather, it recognizes the supplier's responsibility - per condition five above - to ensure that the item is actually delivered to the beneficiary's home on the date of discharge.) No one may bill for the days prior to the date of discharge.

2. If the supplier fits the item to the beneficiary, or trains the beneficiary in its use while the beneficiary is in the facility, but thereafter removes the item and subsequently delivers it to the beneficiary's home, then the date of service must be the date of actual delivery of the item, provided such date is not earlier than the date of discharge.

3. If the supplier leaves the item at the facility and the beneficiary does not take the item home, or a third party does not send it to the beneficiary's home, or the supplier does not otherwise (re)deliver the item to the beneficiary's home on or before the date of discharge, the date of service must not be earlier than the actual date of delivery of the item, i.e., the actual date the item arrives, by whatever means, at the beneficiary's home.

Saturday, August 13, 2016

Pre-Discharge Delivery of DMEPOS for Fitting and Training



The following are CMS policy and billing procedures regarding the circumstances under which a supplier may deliver durable medical equipment, prosthetics, and orthotics - but not supplies - to a beneficiary who is in an inpatient facility that does not qualify as the beneficiary's home.


 Conditions That Must Be Met



In some cases, it would be appropriate for a supplier to deliver a medically necessary item of durable medical equipment (DME), a prosthetic, or an orthotic - but not supplies -to a beneficiary who is an inpatient in a facility that does not qualify as the beneficiary's home. The CMS will presume that the pre-discharge delivery of DME, a prosthetic, or an orthotic (hereafter "item") is appropriate when all the following conditions are met:

1. The item is medically necessary for use by the beneficiary in the beneficiary's home.

2. The item is medically necessary on the date of discharge, i.e., there is a physician's order with a stated initial date of need that is no later than the date of discharge for home use.

3. The supplier delivers the item to the beneficiary in the facility solely for the purpose of fitting the beneficiary for the item, or training the beneficiary in the use of the item, and the item is for subsequent use in the beneficiary's home.

 4. The supplier delivers the item to the beneficiary no earlier than two days before the day the facility discharges the beneficiary.

5. The supplier ensures that the beneficiary takes the item home, or the supplier picks up the item at the facility and delivers it to the beneficiary's home on the date of discharge.

6. The reason the supplier furnishes the item is not for the purpose of eliminating the facility's responsibility to provide an item that is medically necessary for the beneficiary's use or treatment while the beneficiary is in the facility. Such items are included in the Diagnostic Related Group (DRG) or Prospective Payment System (PPS) rates.

7. The supplier does not claim payment for the item for any day prior to the date of discharge.

8. The supplier does not claim payment for additional costs that the supplier incurs in ensuring that the item is delivered to the beneficiary's home on the date of discharge. The supplier cannot bill the beneficiary for redelivery.

9. The beneficiary's discharge must be to a qualified place of service (e.g., home, custodial facility), but not to another facility (e.g., inpatient or skilled nursing) that does not qualify as the beneficiary's home.

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