Wednesday, September 28, 2016

DME payment catagory

 General Payment Rules


DMEPOS are categorized into one of the following payment classes:

• Inexpensive or other routinely purchased DME;

• Items requiring frequent and substantial servicing;

• Certain customized items;

• Other prosthetic and orthotic devices;

• Capped rental items; or

• Oxygen and oxygen equipment.

The CMS determines the category that applies to each HCPSC code and issues instructions when changes are appropriate. See §§130 for billing information for each payment class. DME, including DME furnished under the home health benefit and Part B DME benefit, is paid on the basis of the fee schedule.


Oxygen and oxygen equipment are paid on the basis of a fee schedule.

Any DME or oxygen furnished to inpatients under a Part A covered stay is included in the SNF or hospital PPS rate. When an inpatient in a hospital or SNF is not entitled to Part A inpatient benefits, payment may not be made under Part B for DME or oxygen provided in the hospital or SNF because such facilities do not qualify as a patient's home. The definition of DME in §1861(n) of the Act provides that DME is covered by Part B only when intended for use in the home, which explicitly does not include a SNF or hospital. (See the Medicare Benefit Policy Manual, Chapter 15). This does not preclude separate billing for DME furnished after discharge.

Payment to providers and suppliers other than Home Health Agencies (HHAs) for supplies that are necessary for the effective use of DME is made on the basis of a fee schedule, except that payment for drugs is made under the drug payment methodology rules (See Chapter 17 for drug payment information.)

Payment for prosthetics and orthotics is made on the basis of a fee schedule whether it is billed to the DMERC or the FI.
Payment under Part B for surgical dressings is made on the basis of the fee schedule except:

• Those applied incident to a physician's professional services;

• Those furnished by an HHA; and

• Those applied while a patient is being treated in an outpatient hospital department.

Sunday, September 25, 2016

Home Health Consolidated Billing and Supplies Provided by DMEPOS Suppliers

Section 1842 (b)(6)(F) of the Social Security Act requires consolidated billing of all home health services while a beneficiary is under a home health plan of care authorized by a physician. Consequently, Medicare makes payment for all such items and services to a single home health agency (HHA) overseeing that plan.

The law states payment will be made to the HHA without regard as to whether or not the item or service was furnished by the agency, by others under arrangement to the HHA, or when any other contracting or consulting arrangements exist with the primary HHA, or “otherwise.” Payment for all items is included in the home health prospective payment system (HH PPS) episode payment the HHA receives.

Nonroutine medical supplies are among the types of services that are subject to the home health consolidated billing provision. Medicare periodically publishes Recurring Update Notifications that contain updated lists of nonroutine supply codes that must be included in home health consolidated billing. These services may not be billed separately by a DMEPOS supplier when a Medicare beneficiary is in a HH PPS episode of care.

Durable Medical Equipment (DME), including prosthetics, orthotics and oxygen, is exempt from home health consolidated billing by law.


MERC Systems



The ViPs shall allow the DMERCs the flexibility to report CMN edits as medical review or claims processing workload.

Thursday, September 22, 2016

Billing Partial Month Stays For Capped Rental Equipment


A. General Rule

For capped rental DME items where the DME supplier submits a monthly bill, the date of delivery (the “from” date) on the first claim must be the “from”, or “anniversary date”, on all subsequent claims for the item. For example, if the first claim for a wheelchair is dated September 15, all subsequent bills must be dated on the 15th of the following months (October 15, November 15, etc.).
The following instructions discuss DME payment when the DME is furnished during a month in which the beneficiary spends part of the month in a SNF, and part of the month in his or her own home. In accordance with DME payment policy, Medicare will make separate payment for a full month for DME items in such situations, provided the beneficiary was in the home on the “from” date or “anniversary date” defined above.


B. Policy

If a beneficiary using DME is at home on the “from” or “anniversary date”, Medicare will make payment for DME for the entire month, even if the “from” date is the date of discharge from the SNF.

If a beneficiary using DME is in a covered Part A stay in a SNF for a full month, Medicare will not make payment for DME for that month.

For capped rental items, if the covered Part A SNF stay overlaps the “from” or “anniversary date” of the Certificate of Medical Necessity (CMN), and the beneficiary is not in the covered Part A SNF stay for the entire month, the date of discharge becomes the new “anniversary date” for subsequent claims. In this situation, the supplier must submit a new claim with the date of discharge as the new anniversary date upon the beneficiary’s release from the SNF. Suppliers should annotate claims, to indicate that the patient was in a SNF, resulting in the need to establish a new anniversary date.

NOTES: The DME MACs must continue to make payment for maintenance and servicing of capped rental items regardless of whether the beneficiary is in a covered Part A SNF stay on the date of service of the maintenance and servicing claim.
The DME MACs must make payment for DME on the date of discharge from a covered Part A SNF stay. Claims must edit based on the “from” date of the claim and not the “through” date of the claim.


EXAMPLE 1:

A beneficiary rents a wheelchair beginning on January 1. The DME MAC determines that the wheelchair is medically necessary and that the beneficiary meets all coverage criteria, and so begins to make payment on the wheelchair. The beneficiary enters a covered Part A stay in a SNF on February 15 and is discharged on April 5. In this example, Medicare will make payment for the entire month of February, because the patient was in the home for part of the month. However, the DME MAC will deny the  claim for March, because the patient was in a covered Part A stay in the SNF for the entire month.

Because the anniversary date (“from” date) of the monthly bill was April 1, and the patient was still in the covered Part A stay in a SNF on that date, the DME supplier must not submit another claim until April 5 (the date of discharge). April 5 becomes the new anniversary date (“from” date) for billing purposes, so the supplier would now bill on the 5th of the month rather than the 1st of the month for the remainder of the capped rental period. The supplier should annotate the claim to indicate that the patient was in a SNF on the first claim with the new anniversary date.

EXAMPLE 2:

A beneficiary receives oxygen on January 1. On February 28, the patient enters a covered Part A stay in a SNF and is discharged on March 15.

In this example, the DME MAC would deny a claim dated March 1. The supplier would submit a new claim dated March 15, which would then become the anniversary date for billing purposes. The supplier should annotate the claim to indicate that the patient was in a covered Part A stay in a SNF on the first claim with the new anniversary date.

EXAMPLE 3:

A beneficiary rents a hospital bed beginning on January 1. On March 15, the patient enters a covered Part A stay in a SNF and is discharged on March 25.

In this example, the DME MAC will make payment for the entire month of March.

NOTE: The changes in the general policy in this instruction apply to all items of DME paid by the DME MACs. However, changes in “anniversary date” billing requirements only apply to capped rental DME.

Tuesday, September 20, 2016

CWF Crossover Editing for DMEPOS Claims During an Inpatient Stay with example


I. General Information

A. Background:
In general, the DMEPOS benefit is meant only for items a beneficiary is using in his or her home. For a beneficiary in a Part A inpatient stay, an institutional provider (e.g., hospital) is not defined as a beneficiary’s home for DMEPOS, and so Medicare does not make separate payment for DMEPOS when a beneficiary is in the institution. The institution is expected to provide all medically necessary DMEPOS during a beneficiary’s covered Part A stay.

EXCEPTION: Medicare makes a separate payment for a full month for DMEPOS items, provided the beneficiary was in the home on the “from” date or anniversary date defined below.

For capped rental items of durable medical equipment (DME) where the DME supplier submits a monthly bill, the date of delivery (“from” date) on the first claim must be the “from” or anniversary date on all subsequent claims for the item. For example, if the first claim for a wheelchair is dated September 15, all subsequent bills must be dated for the 15th of the following months (October 15, November 15, etc.).


B. Policy:

If a beneficiary using DMEPOS is at home on the “from” date or anniversary date, Medicare pays for the DMEPOS for the entire month, even if the “from” date is the date of discharge from the institutional provider.

If a beneficiary using DMEPOS is in a covered Part A stay for a full month, Medicare does not make payment for the DMEPOS for that month.

For capped rental items, if the covered Part A stay overlaps the anniversary date (“from” date on the claim), and the beneficiary is not in the covered Part A stay for the entire month, the date of discharge becomes the new anniversary date (“from” date on the claim) for subsequent claims. In this situation, the supplier must submit a new claim with the date of discharge as the new anniversary date upon the beneficiary’s release from the institution. Suppliers should annotate the claims, to indicate that the patient was in an institution, resulting in the need to establish a new anniversary date.

The CWF:

• rejects a DME MAC claim that contain DMEPOS HCPCS codes when the DME MAC claim has a date of service that falls within the inpatient stay;

• considers an inpatient stay to include all days prior to the date of discharge;

• processes a DME MAC claim that contain DMEPOS HCPCS codes when the DME MAC claim has the same “from” date equal to the date of inpatient discharge;

• validates for a crossover service on a DME MAC claim for an inpatient beneficiary based on the “from” date only of the DME MAC claim;

• identifies a DME MAC claim for maintenance and servicing by the “MS” modifier;

• allows payment for a DME MAC claim for maintenance and servicing of capped rental items when a claim contains the “MS” modifier.


The CWF approves to pay maintenance and servicing claims regardless of whether the beneficiary is in an institutional setting or in the home environment.

The changes in the general policy apply to all items of DMEPOS paid by the DME MACs, however, changes in anniversary date billing apply only to capped rental DME.

In cases where the anniversary date falls at the end of the month (for example January 31) and a subsequent month does not have a day with the same date (for example, February), the DME MAC uses the final date in the calendar month (for example, February 28).

EXAMPLE 1:

A beneficiary rents a wheelchair beginning on January 1. The DME MAC determines that the wheelchair is medically necessary and that the beneficiary meets all coverage criteria, and so begins to make payment on the wheelchair. The beneficiary enters a covered a hospital on February 15 and is discharged on April 5.

In this example, Medicare pays for the entire month of February, because the patient was in the home for part of the month. However, the DME MAC denies the claim for March, because the patient was in a covered hospital stay for the entire month.

Because the anniversary date (“from” date) of the monthly bill was April 1, and the patient was still in the covered hospital stay on that date, the DME supplier must not submit another claim until April 5 (the date of discharge). April 5 becomes the new anniversary date (“from” date) for billing purposes, so the supplier would now bill on the 5th of the month rather than the 1st of the month for the remainder of the capped rental period. The supplier should annotate the claim to indicate that the patient was in a hospital on the first claim with the new anniversary date.


EXAMPLE 2:

A beneficiary receives oxygen on January 1. On February 28, the patient enters a hospital and is discharged on March 15.
In this example, the DME MAC denies a claim dated March 1. The supplier submits a new claim dated March 15, which would then become the anniversary date for billing purposes. The supplier should annotate the claim to indicate that the patient was in a hospital on the first claim with the new anniversary date.

EXAMPLE 3:

A beneficiary rents a hospital bed beginning on January 1. On March 15, the patient enters a hospital and is discharged on March 25.
In this example, the DME MAC pays for the entire month of March.

EXAMPLE 4:

A beneficiary rents a wheelchair beginning December 15. On January 1, the patient enters a hospital and is discharged on January 31.

In this example, the DME MAC denies the claim dated January 15. The supplier submits a new claim dated January 31, which becomes the anniversary date for billing purposes. The supplier should annotate the claim to indicate that the patient was in a hospital on the first claim with the new anniversary date. The February claim would be dated February 28 because there is no 31st day in February.

Sunday, September 18, 2016

Automatic Mailing/Delivery of DMEPOS


Suppliers/manufacturers may not automatically deliver DMEPOS to beneficiaries unless the beneficiary, physician, or designated representative has requested additional supplies/equipment. The reason is to assure that the beneficiary actually needs the DMEPOS. Contractor review should be done on a post-pay basis.

A beneficiary or their caregiver must specifically request refills of repetitive services and/or supplies before a supplier dispenses them. A supplier may not initiate a refill of an order. The supplier must not automatically dispense a quantity of supplies on a predetermined regular basis.

A request for refill is different than a request for a renewal of a prescription. Generally, the beneficiary or caregiver will rarely keep track of the end date of a prescription. Furthermore the physician is not likely to keep track of this. The supplier is the one who will need to have the order on file and will know when the prescription will run out and a new order is needed. It is reasonable to expect the supplier to contact the physician and ask for a renewal of the order. This is consistent with the DMERC Supplier Manual, which states: "The description of the item (on an order) may be completed by someone other than the physician (most commonly the supplier). However, the physician must review the order and sign and date it to indicate agreement." Again the supplier must not automatically mail or deliver the DMEPOS to the beneficiary until specifically requested.

The DMERCs inform suppliers of these procedures via their bulletins and training sessions. These procedures will benefit suppliers by helping to maximize claims processing accuracy, and to reduce the likelihood of a postpayment claim denial because the DMEPOS were not medically necessary.

DMERCs must publish this information on their Web sites and in their bulletins on an annual basis.

Thursday, September 15, 2016

Patient Liability to a Provider Other Than a HHA on DME claims with examples


To determine patient liability to a provider other than a HHA (including nominal charge providers other than a HHA), FIs subtract any unmet deductible from the actual charge and multiply the remainder by 20 percent. The result, plus the unmet deductible is the patient's liability. Coinsurance is applied as applicable.

The following describes application of deductible and coinsurance on HHA bills by bill type:

a. Patient Under Part B Plan of Treatment (Bill Type 32X)

• No deductible applicable; and

• No coinsurance applicable

Exception: Coinsurance applies on DME and orthotic/prosthetic claims.

b. Patient Under Part A Plan of Treatment (Bill Type 33X)

• No deductible applicable; and

• No coinsurance applicable

EXCEPTION: Coinsurance applies on DME and orthotic/prosthetic claims.

c. Patient Not Under Plan of Treatment, Part B Medical and Other Health Services and Osteoporosis Injections (Bill Type 34X)

• Deductible applies; and

• Coinsurance applies

The following examples illustrate how to calculate provider payment and patient liability in various situations. The examples like the proceeding rules for HHAs address items and services not under a Plan of Care and, therefore, include deductible application. The
Note following each HHA example addresses items and services obtained under a Plan of Care and, therefore, do not address deductible application.

EXAMPLE 1: CLAIM CONTAINING ONLY ORTHOTIC/PROSTHETIC CHARGES

$200.00 Orthotic/prosthetic charges

$140.00 Orthotic/prosthetic fee schedule amount

$100.00 Part B deductible to be met

To determine the payment to all providers (other than nominal charge HHAs) apply the following steps:


Step 1:

Determine the lower of the actual charge or the fee schedule amount: $140.00 (do not apply the provider's interim rate)

Step 2:

Subtract any unmet Part B deductible from the amount determined in Step 1: $140.00 - $100.00 = $40.00

Step 3:

Apply 80% to the amount determined in Step 2: $40.00 X 80% = $32.00

The Part B payment to the provider in this example is $32.00.


To determine payment to nominal charge HHAs apply the following steps:


Step 1:

Subtract any unmet deductible from the fee schedule amount: $140.00 - $100.00 = $40.00

Step 2:

Apply 80% to the amount determined in Step 1: $40.00 x 80% = $32.00

The Part B payment to the nominal charge HHA in this example is $32.00


NOTE: If the item or service is covered under a Home Health Plan of Care, the payment is determined the same way, except no deductible is applicable. In the above examples the payment would be $112.00 ($140.00 x 80%).

To determine beneficiary liability to providers other than HHAs apply the following steps:

Step 1:

Subtract any unmet Part B deductible from the actual charge: $200.00 - $100.00 = $100.00

Step 2:

Multiply the amount determined in Step 1 by 20% coinsurance: $100.00 x 20% = $20.00

Step 3:

Add the result of Step 2 to the unmet deductible: $20.00 + $100.00 = $120.00

The beneficiary's liability in this example is $120.00. ($100.00 Part B deductible and $20.00 coinsurance.)

To determine beneficiary liability to HHAs (other than nominal charge) apply the following steps:

Step 1:

Subtract any unmet deductible from the lower of the actual charge or the fee schedule amount: $140.00 - $100.00 = $40.00

Step 2:

Multiply the amount determined in Step 1 by 20% coinsurance: $40.00 X 20% = $8.00

Step 3:

Add the result of Step 2 to the unmet deductible: $8.00 + $100.00 = $108.00

The beneficiary's liability in this example is $108.00 ($100.00 Part B deductible an $8.00 coinsurance.)

NOTE: If the item or service is covered under a Home Health Plan of Care, the beneficiary's liability is determined the same way, except no deductible is applicable. In this example the beneficiary's liability would be $28.00 ($140.00 x 20% coinsurance).



To determine beneficiary liability to nominal charge HHAs apply the following steps:

Step 1:

Subtract any unmet Part B deductible from the fee schedule amount: $140.00 - $100.00 = $40.00


Step 2:

Multiply the amount determined in Step 1 by 20% coinsurance: $40.00 x 20% = $8.00

Step 3:

Add the result of Step 2 to the unmet deductible: $8.00 + $100.00 = $108.00


The beneficiary's liability in this example is $108.00 ($100.00 Part B deductible and $8.00 coinsurance).

NOTE: If the item of service is covered under a Home Health Plan of Care, the beneficiary's liability is determined the same way, except no deductible is applicable. In this example, the beneficiary's liability would be $28.00 ($140.00 x 20% coinsurance).

Example 2: CLAIM CONTAINING ONLY ORTHOTIC/PROSTHETIC CHARGES - NEGATIVE PAYMENT
$120.00 Orthotic/prosthetic charges


$ 80.00 Orthotic/prosthetic fee schedule amount

$100.00 Part B deductible to be met

To determine the payment to all providers (other than nominal charge HHAs) apply the following steps:

Step 1:

Determine the lower of the actual charge or the fee schedule amount: $80.00 (do not apply the provider's interim rate)

Step 2:

Subtract any unmet Part B deductible from amount determined in Step 1: $80.00 - $100.00 = -$20.00

Do not apply the 80 percent since the result of Step 2 is a negative amount. There is no Part B payment to the provider in this example because the result equals a negative payment amount. FIs do not take the negative amount of (-$20.00) from future payments to the provider.

To determine payment to nominal charge HHAs, apply the following step:


Step 1:

Subtract any unmet deductible from the fee schedule amount: $80.00 - $100.00 = -$20.00

Do not apply the 80 percent since the result of Step 1 is a negative amount. There is no Part B payment to the nominal charge HHA in this example because the result equals a negative payment amount. RHHIs do not take the negative amount of (-$20.00) from future payments to the HHA.

NOTE: If the item or service is covered under a Home Health Plan of Care the payment is determined in the same way, except no deductible is applicable. In the above examples the payment would be $64.00 ($80.00 x 80%).


To determine beneficiary liability to providers other than HHAs, apply the following steps:

Step 1:

Subtract any unmet Part B deductible from the actual charge: $120.00 - $100.00 = $20.00

Step 2:

Multiply the amount in Step 1 by 20% coinsurance: $20.00 x 20% = $4.00

The beneficiary's liability in this example is $104.00 ($100.00 Part B deductible and $4.00 coinsurance).


The beneficiary's liability to HHAs (nominal charge and other than nominal charge) in this example is $80.00 (the fee schedule amount for nominal charge HHAs or the lower of the fee schedule amount or the actual charge for other than nominal charge HHAs). The HHA cannot charge the beneficiary the $100.00 deductible since it exceeds $80.00.

$80.00 is credited to the beneficiary's deductible. The beneficiary's deductible to be met on the next claim is $20.00. The beneficiary has no coinsurance obligation.

NOTE: If the item or service is covered under a Home Health Plan of Care, the beneficiary's liability is determined the same way, except that no deductible is applicable. The beneficiary's liability in this example would be $16.00 coinsurance ($80.00 x 20%).

Tuesday, September 13, 2016

Billing for Splints and Casts


The cost of supplies used in creating casts are not included in the payment amounts for the CPT codes for fracture management and for casts and splints. Thus, for settings in which CPT codes are used to pay for services that include the provision of a cast or splint, supplies maybe billed with separate CPCS codes. The work and practice expenses involved with the creation of the cast or splint are included in the payment for the code for that service.

For claims with dates of service on or after July 1, 2001, jurisdiction for processing claims for splints transferred from the DME MACs to the A/B MAC (B). The A/B MACs (B) have jurisdiction for processing claims for splints and casts, which includes codes for splints that may have previously been billed to the DME MACs.

Jurisdiction for slings is jointly maintained by the A/B MACs (B) (for physician claims) and the DME MACs (for supplier claims). Notwithstanding the above where the beneficiary receives the service from any of the following providers claims jurisdiction is with the A/B MAC (A). An exception to this is hospital outpatient services and hospital inpatient Part B services, which are included in the OPPS payment and are billed to the A/B MAC (A) using the ASC X12 837 institutional claim format or Form CMS- 1450).

Other providers and suppliers that normally bill the A/B MAC (A) for services bill the A/B MAC (B) for splints and casts.

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