Coverage Table for DME Claims (Rev. 1, 10-01-03)

by  Jared Staheli
June 17th, 2015

Reimbursement may be made for expenses incurred by a patient for the rental or purchase of durable medical equipment (DME) for use in his/her home provided that all the conditions in column A below have been met. Column B indicates the action contractors will take to establish that the conditions have been met.

A - Conditions B - Review Action
1. Payment may be made for the following: 1. Payment may be made for following:
(a) Items of DME that are medically necessary (a) The HCPCS file shows coverage status of items. If item is not listed in the HCPCS file, the contractor will develop LMRP to determine whether the item is covered.
(b) Separate charges for repair, maintenance and delivery

(b) Repairs - only if DME is being purchased or is already owned by patient and repair is necessary to make the equipment serviceable. Medicare pays the least expensive alternative. (See special exception in Chapter 15 of the Medicare Benefit Policy Manual for repair of dialysis delivery system.)

NOTE: See Chapter 15 of the Medicare Benefit Policy Manual for handling claims suggesting deliberate or malicious damage or destruction

Maintenance - only if the equipment is being purchased, or is already owned by the patient, and if the maintenance is extensive amounting to repairs, i.e., requiring the services of skilled technicians. (Contractors deny claims for routine maintenance and periodic servicing, e.g., testing, cleaning, checking, oiling, etc.) (See special exception in Chapter 15 of the Medicare Benefit Policy Manual for maintenance of dialysis delivery system.)

Delivery - of rented or purchased equipment is covered, but the related payment is included in the fee schedule for the item. Additional payment may be made at the discretion of the contractor in special circumstances (see Chapter 15 of the Medicare Benefit Policy Manual)

(c) Separate charges for disposable supplies, e.g., oxygen, if essential to the effective use of medically necessary durable medical equipment. Separate charges for replacement of essential accessories such as hoses, tubes, mouthpieces, etc., only if the beneficiary owns or is purchasing durable medical equipment (BPM, Chapter 15, §110). (Medications used in connection with durable medical equipment are covered under certain conditions - see Chapter 15 of the Medicare Benefit Policy Manual)

(c) Claim must indicate that:

• The patient has the DME for which the supply is intended;

• The DME continues to be medically necessary; and

• The items are readily identifiable as the type customarily used with such equipment.

NOTE: If the quantity of accessories and/or supplies included in a claim seems excessive or if claims for such items are received from the same claimant with undue frequency, see Chapter 5 of the Medicare Program Integrity Manual.

2. DME must be for use in patient's residence other than a health care institution. (BPM §110.3 & PIM, Chapter 5, §1)

2. Payment cannot be made for equipment for use in an institution classified as:

a. A participating hospital,

b. An emergency hospital,

c. Meets §1861(e)(1) of the Act,

d. A participating SNF or

e. Meets §1819(a)(1) of the Act.

Except for a distinct part of a SNF, if one of these institutions has a distinct part that does not meet 1819(a)(1), the patient may be considered in his/her residence if he/she was physically located in such distinct part during the use period.

DMEPOS (DME, P&O, and supplies) items provided to hospice patients are generally included in the payment for hospice services. Items of DMEPOS are covered by Medicare and paid in addition to the hospice payment only when those items or supplies are provided to the patient for treatment of a condition or illness not related to the patient's terminal illness.

3. Physician's prescription required. A supplier must maintain and, upon request, make available to the contractor, the detailed written order (or, when required, the Certificate of Medical Necessity (CMN)) from the treating physician. See the Medicare Program Integrity Manual, Chapter 5.

 

References:

Coverage Table for DME Claims (Rev. 1, 10-01-03). (2015, June 17). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/coverage-table-for-dme-claims-26669.html

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