Reimbursement for most Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) is established by fee schedules. Payment is limited to the lower of the actual charge or the fee schedule amount.
The fee schedule classifies most DMEPOS into one of six categories explained below:
Inexpensive or other routinely purchased DME
Items requiring frequent and substantial servicing
Customized items
Other prosthetic and orthotic devices
Capped rental items
Oxygen and oxygen equipment
For some basic information to get you started including modifiers and how CMS views DMEPOS CLICK HERE
Select the title to see a summary and a link to the full article.
August 13th, 2019
Healthcare Common Procedure Coding System (HCPCS)
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 13th, 2019
There are three main code sets and Healthcare Common Procedure Coding System (HCPCS), is the third most common code set used. They are often called Level II codes and are used to report non-physician products supplies and procedures not found in CPT, such as ambulance services, DME, drugs, orthotics, supplies, ...
By Wyn Staheli, Director of Research | Published July 9th, 2019
Othoses often have extra components. When can you bill those components separately? For example, can you bill for a suspension sleeve (L2397) with a knee orthosis (e.g., L1810)?
Electrical Stimulation and Electromagnetic Therapy Devices
By Raquel Shumway | Published May 13th, 2019 - Last Review/Update May 20th, 2019
Electrical Stimulation and Electromagnetic Therapy Devices can be used for pain, muscle atrophy, help spinal cord injuries, treat symptoms caused by other medical conditions and can be used in the treatment of wounds. This Regence BC/BS article lists codes and devices and gives guidance on coding from Medicare Advantage viewpoint.
By Wyn Staheli, Director of Research | Published November 29th, 2018
While equipment for home strengthening is arguably good for the patient and the prognosis of their condition(s), payers have very strict guidelines as to what is considered medically necessary when it comes to Durable Medical Equipment (DME). While I have seen some workers compensation policies which do pay for DME ...
By Find-A-Code | Published October 26th, 2018 - Last Review/Update January 9th, 2019
CMS Gives guidance on Capped Rental Items:
Items in this category are paid on a monthly rental basis not to exceed a period of continuous use of 13 months.
Based on Supplier Standard 5, suppliers are required to advise beneficiaries of the rent/purchase option for capped rentals and inexpensive or routinely purchased items. ...
The Certificate of Medical Necessity (CMN) for Oxygen is a required form that helps to document the medical necessity for oxygen therapy. It also documents other coverage criteria for the oxygen use. For payment on a home oxygen claim, the information in the supplier’s records or the patient’s medical record must be substantiated with the information in the CMN.
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Breastfeeding Supplies
Procedure Codes A4286: Locking ring for breast pump, replacement E0602: Breast pump, manual, any type E0603: Breast pump, electric (ac and/or dc), any type E0604: Breast pump, hospital grade, electric (ac and / or dc), any type S9443: Lactation classes, non-physician provider, per session
ICD-10-CM ...
As per MLN MM8304,
This article is based on Change Request (CR) 8304, which instructs DME MACs to implement requirements, which are effective July 1, 2013, for detailed written orders for face-to-face encounters conducted by the physician, PA, NP or CNS for certain DME items as defined in 42 CFR 410.38(g).
Due to concerns ...
Coverage Criteria for Nonwearable Automatic Defibrillators
By Find-A-Code | Published April 19th, 2018
According to Noridian and CGS Administrators LCD L33690, a nonwearable automatic defibrillator (E0617) is covered for beneficiaries in two circumstances. They meet either (1) both criteria A and B or (2) criteria C, described below:
The beneficiary has one of the following conditions (1-8):A documented episode of cardiac arrest due to ventricular fibrillation, not due to a ...
CMS Changes Definitions for Therapeutic Shoe Inserts
By Wyn Staheli, Director of Research | Published February 1st, 2018
CMS recently revised their definitions for custom fabricated and therapeutic inserts in order to meet current technology standards. Healthcare providers need to be sure to review the revisions in order to appropriately bill Medicare for inserts. For example, for custom fabricated, molded-to-patient, they have added the following:
iii. For inserts used with ...
Properly documenting DME orders is crucial for reimbursement. It should be noted that without meeting the payer requirements, the claim will be denied. For Medicare, the beneficiary will not be responsible for paying for the item if the provider and/or supplier do not meet requirements. Commercial payers have similar policies so carefully ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 15th, 2016
The Patient Access and Medicare Protection Act (PAMPA) was recently signed into law on December 28, 2015. Beginning January 1, 2016, the DME fee schedule rates are adjusted to reflect information from the DMEPOS competitive bidding program as required by section 1834(a)(1)(F)(ii) of the Social Security Act. These adjustments are ...
CMS Announces: Final Rule on Authorization Process for Certain Durable Medical Equipment
By Brittney Murdock, QCC, CMCS, CPC | Published January 5th, 2016
CMS has established a new prior authorization process for DMEPOS items that are frequently subject to unnecessary utilization. The final rule will create an initial Master list that includes items that meet specific criteria.
Items already on the Master List that are identified by a GAO/OIG, or CERT DME and/or DMEPOS ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 24th, 2015
Prescription (order) Requirements face-to-face examination is required each time a new prescription for one of the specified items is ordered. A new prescription is required by Medicare:
• For all claims for purchases or initial rentals
• When there is a change in the prescription for the accessory, supply, drug, etc.
• If ...
Prescription (order) Requirements for Durable Medical Equipment
By Find-A-Code | Published November 24th, 2015
The supplier for all Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) is required to keep on file a physician prescription (order). A supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary.
Hospital Billing For Take-Home Drugs (Rev. 3085, Effective: Upon Implementation of ICD-10)
By Jared Staheli | Published July 9th, 2015
All hospitals, including critical access hospitals (CAHs), bill the appropriate DME MAC for take-home supplies of oral anti-cancer drugs, oral anti-emetic drugs and multi-day supplies of immunosuppressive drugs, as well as the associated supplying fees. All inhalation drugs and the associated dispensing fees are also billed to the DME MAC.
Claims ...
Intravenous Immune Globulin (Rev. 3085, Effective: Upon Implementation of ICD-10)
By Jared Staheli | Published July 9th, 2015
Beginning for dates of service on or after January 1, 2004, Medicare pays for intravenous immune globulin administered in the home. (See the Medicare Benefit Policy Manual, Chapter 15 for coverage requirements.) Contractors pay for the drug, but not the items or services related to the administration of the drug ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 8th, 2015
The following table contains repair units of service allowances for commonly repaired items billed under HCPCS code K0739 (Repair or Non-routine Service for Durable Medical Equipment Other than Oxygen Equipment Requiring the Skill of a Technician, Labor Component, Per 15 Minutes). This applies to non-rented and out-of-warranty items.
When billing for ...
Calculation of the Payment Allowance Limit for DMERC Drugs (Rev. 397, 01-03-05)
By Jared Staheli | Published July 8th, 2015
Payments for drugs billed to the DMERCs will be based on the implementation of the MPDIMA, beginning January 1, 2004, and will be paid at 85 percent of the AWP for HCPCS payment amounts based on the April 1, 2003 fee schedule. Exceptions to this calculation are as follows:
The payment ...
DMEPOS Suppliers Require a License to Dispense Drugs (Rev. 1, 10-01-03)
By Jared Staheli | Published July 8th, 2015
Regulations at 42 CFR 424.57(b)(4) (supplier standards) state that a “supplier that furnishes a drug used as a Medicare-covered supply with durable medical equipment or prosthetic devices must be licensed by the State to dispense drugs. (A supplier of drugs must bill and receive payment for the drug in its ...
Durable Medical Equipment Medicare Administrative Contractors (DME MAC) Designation for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
There are four DME MACs assigned to geographical regions. Jurisdiction for DME claims is based upon the permanent residence of the beneficiary, regardless of the location of the supplier submitting the claim. The IHS facilities shall enroll with the National Supplier Clearinghouse (NSC) to obtain a supplier number for billing ...
Provider Enrollment with DME MAC for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
All IHS providers and suppliers that do not currently have a supplier number and want to bill for DMEPOS items must enroll with the NSC.
Beginning July 1, 2005, IHS providers (including CAHs) and pharmacies were eligible to begin billing for DME. The NSC must accept enrollment applications from IHS and ...
NSC Supplier Number for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
To enable direct billing of DMEPOS, an IHS supplier must enroll with the NSC as a “DME Supplier”, secure a Medicare supplier billing number and comply with the supplier standards specified in 42 CFR §424.57, and submit all DME claims to the appropriate DME MAC based on current DME jurisdiction ...
DME General Information for Indian Health Services (Rev.2075, 01-28-11)
By Jared Staheli | Published June 25th, 2015
The DME MACs process claims for items of DMEPOS for use in the beneficiary’s home. Beginning January 1, 2005, Medicare Part B makes payment for medically necessary items of DME, prosthetics, orthotics, and supplies to IHS suppliers that furnish DME for use in the beneficiary’s home. See Pub. 100-02, Medicare ...
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Payment Policy for Indian Health Services (Rev. 2075, 01-28-11)
By Jared Staheli | Published June 25th, 2015
Section 630 of the MMA, indefinitely extended by §2902 of the ACA, permits IHS suppliers to directly bill for itemized DMEPOS with dates of service (DOS) on or after January 1, 2005. Previously IHS suppliers could not directly bill Medicare for DMEPOS.
...
Licensure to Dispense Drugs for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
In order to bill drugs to the DME MACs, the supplier must be a pharmacy. States may not regulate the qualifications of Federal employees who are carrying out their authorized Federal activities within the scope of their employment. However, IHS employees are not subject to state licensure laws and IHS ...
Payment for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Surgical dressings, splints, casts, DME and other devices used for reductions of fractures and dislocations are paid based on the DMEPOS fee schedule. Claims will be priced using the appropriate DMEPOS fee schedule based on the beneficiary’s address.
Payment for DME MAC-covered drug claims shall be based on the ASP fee ...
Services Billed to the DME MAC for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Effective July 1, 2005, IHS suppliers and IHS providers (including CAHs) shall bill the appropriate DME MAC for DME.
Although, parenteral and enteral nutrients, equipment, and supplies meet the definition of the prosthetic benefit, they are separately billable to the DME MAC for home use. Ostomy, tracheostomy, and urological supplies meet ...
General Claims Processing Rules for DMEPOS for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The DME MACs may only be billed for surgical dressings, splints, casts and for prosthetics and orthotics by IHS suppliers, not by IHS providers. The Region D DME MAC shall accept all DMEPOS claims submitted by IHS suppliers and shall forward electronic media claims to the appropriate DME MAC for ...
General Documentation Requirements (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
Benefit policies are set forth in the Medicare Benefit Policy Manual, Chapter 15, §§110- 130.
Program integrity policies for DMEPOS are set forth in the Medicare Program Integrity Manual, Chapter 5.
See Chapter 21 for applicable MSN messages.
See Chapter 22 for Remittance Advice coding.
...
Written Order Prior to Delivery (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
See the Medicare Program Integrity Manual, Chapter 5, for requirements for written orders for suppliers, including providers billing the DMERC or carrier as suppliers.
See §01 for definitions of provider and supplier.
...
Certificates of Medical Necessity (CMN) (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
For certain items or services billed to the DME Regional Carrier (DMERC), the supplier must receive a signed Certificate of Medical Necessity (CMN) from the treating physician. CMNs are not required for the same items when billed by HHAs to RHHIs. Instead, the items must be included in the physician's ...
Completion of Certificate of Medical Necessity Forms (Rev. 2993, Upon Implementation of ICD- 10)
By Jared Staheli | Published June 18th, 2015
1. SECTION A: (This may be completed by supplier.)
a. Certification Type/Date - If this is an initial certification for this patient, the date (MM/DD/YY) is indicated in the space marked "INITIAL". If this is a revised certification (to be completed when the physician changes the order, based on the patient's ...
Evidence of Medical Necessity for Parenteral and Enteral Nutrition (PEN) Therapy (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
The PEN coverage is determined by information provided by the treating physician and the PEN supplier. A completed certification of medical necessity (CMN) must accompany and support initial claims for PEN to establish whether coverage criteria are met and to ensure that the PEN therapy provided is consistent with the ...
Scheduling and Documenting Certifications and Recertifications of Medical Necessity for PEN (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
A certification for PEN therapy must accompany the initial claim submitted. The initial certification is valid for six months. Contractors establish the schedule on a case-by-case basis for recertifying the need for PEN therapy. A change in prescription for a beneficiary past the initial certification period does not restart the ...
Completion of the Elements of PEN CMN (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
The patient's name, address, and HICN and the nature of the certification (i.e., initial, renewed, or revised) must be entered on all certifications by the supplier, physician, or physician's designated employees. The supplier identifying information is required on all PEN certifications.
All medical and prescription information must be completed from the ...
DMERC Review of Initial PEN Certifications (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
In reviewing the claim and the supporting data on the CMN, the DMERC compares certain items, especially pertinent dates of treatment. For example, the start date of PEN coverage cannot precede the date of physician certification. The estimated duration of therapy must be contained on the CMN. This information is ...
Evidence of Medical Necessity for Oxygen (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
Oxygen coverage is determined by the results of an arterial blood gas or oximetry test. A CMN for oxygen equipment must include results of specific testing before coverage can be determined.
Suppliers that bill electronically may transmit initial, revised, and recertification CMNs by electronic media using CMS-established standard formats. Information transmitted ...
Scheduling and Documenting Recertifications of Medical Necessity for Oxygen (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
Recertification scheduling and documentation requirements depend on the date when home oxygen therapy began. Contractors request the following information on all recertifications:
• Date and results of the most recent arterial blood gas or oximetry tests prior to the recertification date;
• Name of the provider conducting the most recent arterial blood ...
HHA Recertification for Home Oxygen Therapy (Rev. 2993, Upon Implementation of ICD- 10)
By Jared Staheli | Published June 18th, 2015
Section 1834(a)(5) of the Act requires patients who receive home oxygen therapy and who at the time such services are initiated have an initial arterial blood gas value of 56 or higher or an initial oxygen saturation at or above 89 percent to be retested between 60 and 90 days ...
Contractor Review of Oxygen Certifications (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
All claims with initial certifications calling for oxygen flow rates of more than 4 liters per minute must be reviewed before payment is authorized.
Items Requiring Special Attention -
a. Oxygen Delivery or Supply Prescribed - If the treating physician has specified the oxygen equipment to be supplied, contractors ensure that the ...
Limitations on DMERC Collection of Information (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
The Paperwork Reduction Act (PRA) of 1995 §44 USC 3500, et seq. requires that the Director of the Office of Management and Budget approve any collections of information performed by or for the Federal Government unless the collection fits within exceptions for audits and investigations. Absent such approval, the collection ...
Reporting the Ordering/Referring NPI on Claims for DMEPOS Items Dispensed Without a Physician’s Order (Rev. 1368, 04-07-08)
By Jared Staheli | Published June 18th, 2015
Chapter 5, section 5.2.1 of the Medicare Program Integrity Manual (PIM) states that, in order for Medicare to make payment for an item of Durable Medical Equipment Prosthetic, and Orthotic Supplies (DMEPOS), the DMEPOS supplier must obtain a prescription from the
For Coordination of Benefit purposes, DMEPOS suppliers shall use the ...
General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies (Rev. 330, 04-04-05)
By Jared Staheli | Published June 18th, 2015
Part B suppliers and providers other than Home Health Agencies (HHAs) must bill DMEPOS to the Durable Medical Equipment Regional Carrier (DMERC), except claims for implanted DME. Implanted DME and supplies for the implanted equipment are billed to the local carrier.
Suppliers and providers must have a supplier billing number issued ...
Billing/Claim Formats (Rev. 2993, Upon Implementation of ICD- 10)
By Jared Staheli | Published June 18th, 2015
The DME MAC and the A/B MAC (B) are billed on the ASC X12 837 professional claim format or if permissible Form CMS-1500.
The A/B MAC (A) (including the A/B MAC (HHH)) is billed on the ASC X12 837 institutional claim format or if permissible Form CMS-1450.
Note that the ASC X12 ...
Requirements for Implementing the NCPDP Standard (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
Retail pharmacies will be identified by a value of A5 in the specialty code as received by the National Supplier Clearinghouse. Only DMERC suppliers with an A5 specialty code may use the NCPDP standard. The DMERCs, their EDI submitters, and their other trading partners are required to transmit the NDCs ...
Certificate of Medical Necessity (CMN) (Rev. 867, 04-03-06)
By Jared Staheli | Published June 18th, 2015
The CMN for Parenteral Nutrition (Form CMS-852) is required. The DMERC Information Form for Immunosuppressive Drugs (Form DMERC-08.02) is not required when billing for immunosuppressive drugs with dates of service on or after April 1, 2006. As with other electronic formats, CMN data must be submitted within the valid transaction.
For ...
The DMERCs are to provide the NCPDP companion document, found at: http://cms.hhs.gov/manuals/pm_trans/B03041.pdf to retail pharmacy drug claim submitters (either provider, billing agent, or clearinghouse) that will submit retail pharmacy drug claims to Medicare electronically.
...
Application of DMEPOS Fee Schedule (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
Services that are paid under the DME fee schedule are identified in the DMEPOS fee schedule file available free on the CMS Web Site at: http://www.cms.hhs.gov/providers/pufdownload/default.asp
The DMEPOS fee schedule applies to claims to FIs as follows.
BILL TYPE/ DEFINITION
ORTHOTICS/ PROSTHETICS
DME/ OXYGEN
12X (Hospital inpatient Part B)
Subject to fee schedule
Not covered, therefore, ...
Pre-Discharge Delivery of DMEPOS for Fitting and Training (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
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.
...
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 ...
Date of Service for Pre-Discharge Delivery of DMEPOS (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
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 ...
Facility Responsibilities During the Transition Period (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
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 ...
Frequency of Claims for Repetitive Services (All Providers and Suppliers) (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
HHAs include DMEPOS on bill types 32x or33x with home health visits bill at the freqency required for the home health. See Chapter 10 for home health billing requirements.
Other providers and suppliers, including home health agencies billing the FI on bill type 34x, submit claims on a monthly basis unless ...
DME MACs Only - Appeals of Duplicate Claims (Rev. 2993, Upon Implementation of ICD-10)
By Jared Staheli | Published June 18th, 2015
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 ...
DME MACs – Billing Procedures Related To Advanced Beneficiary Notice (ABN) Upgrades (Rev. 2993, Upon Implementation of ICD- 10)
By Jared Staheli | Published June 18th, 2015
This section provides the DME MACs billing instructions regarding the use of ABNs and claims modifiers for upgrades for items of DMEPOS.
Federal Regulations at 42 CFR 411.408 and Chapter 30 of this manual establishes the basis for a supplier to issue an ABN to a beneficiary. The purpose of the ...
Providing Upgrades of DMEPOS Without Any Extra Charge (Rev. 2993, Upon Implementation of ICD-10)
By Jared Staheli | Published June 18th, 2015
Instead of using ABNs and charging beneficiaries for upgraded items, suppliers in certain circumstances may decide to furnish beneficiaries with upgraded equipment but charge the Medicare program and the beneficiary the same price they would charge for a nonupgraded item. The reason for this may be that a supplier prefers ...
Provider Billing for Prosthetic and Orthotic Devices (Rev. 2629, 02-05-13)
By Jared Staheli | Published June 18th, 2015
See § 01 for definition of provider.
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 ...
Billing for Inexpensive or Other Routinely Purchased DME (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
This is equipment with a purchase price not exceeding $150, or equipment that the Secretary determines is acquired by purchase at least 75 percent of the time, or equipment that is an accessory used in conjunction with a nebulizer, aspirator, or ventilators that are either continuous airway pressure devices or ...
Billing for Items Requiring Frequent and Substantial Servicing (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
These are items such as intermittent positive pressure breathing (IPPB) machines and ventilators, excluding ventilators that are either continuous airway pressure devices or intermittent assist devices with continuous airway pressure devices.
Suppliers and providers other than HHAs bill the DMERC. HHAs bill the RHHI.
...
Billing for Certain Customized Items (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
Due to their unique nature (custom fabrication, etc.), certain customized DME cannot be grouped together for profiling purposes. Claims for customized items that do not have specific HCPCS codes are coded as E1399 (miscellaneous DME). This includes circumstances where an item that has a HCPCS code is modified to the ...
Billing for Capped Rental Items (Other Items of DME) (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
These are DME items, other than oxygen and oxygen equipment, not covered by the above categories. Suppliers and providers other than HHAs bill the DMERC. HHAs bill the RHHIs.
...
Billing for Oxygen and Oxygen Equipment (Rev. 1493; 04- 07-08)
By Jared Staheli | Published June 18th, 2015
The following instructions apply to all claims from providers and suppliers to whom payment may be made for oxygen. The chart in §130.6.1 indicates what is payable under which situation.
...
Oxygen Equipment and Contents Billing Chart (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
The following chart indicates what oxygen fee schedule component is billable/payable under various transaction scenarios for providers and suppliers:
1. Situation: Beneficiary Uses a Stationary System Only
a. Rental Cases (Beneficiary Uses a Stationary System Only)
Type of System
Stationary Monthly Payment
Oxygen Content Fee
Portable Add-On
Portable Contents Fee
Concentrator
Yes
No
No
No
E1377 E1378 E1379 E1380 E1381 E1382 E1383 E1384 ...
Billing for Maintenance and Servicing (Providers and Suppliers) (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
General
Payment is not made for maintenance and servicing if the beneficiary rents the equipment since payment for maintenance and servicing are included in the rental payments. An exception to this is the 6-month service fee for capped rental items that the beneficiary has elected not to purchase (see §40.2 and ...
Where a beneficiary is purchasing an item through installments, the total price of the equipment item is reported on the first bill. Monthly payments are made (by the DMERC, carrier, FI or RHHI). The monthly amount is equivalent to the rental fee schedule amount and is paid until the fee ...
Showing Whether Rented or Purchased (Rev. 2993, Upon Implementation of ICD- 10)
By Jared Staheli | Published June 18th, 2015
Claims must specify whether equipment is rented or purchased. For purchased equipment, the itemized bill or claim must also indicate whether equipment is new or used. If the provider or supplier fails to indicate on an assigned claim whether equipment was new or used, the contractor processing the claims assumes ...
Billing for Supplies and Drugs Related to the Effective Use of DME (Rev. 2993, Upon Implementation of ICD- 10)
By Jared Staheli | Published June 18th, 2015
Suppliers and providers bill supplies that are necessary for the effective use of DME, including drugs, with the appropriate HCPCS code identifying the supply. HHAs must also report revenue code 0294, "Supplies/Drugs for DME Effectiveness."
Suppliers and providers, other than HHAs, bill supplies and drugs (not including drugs that are necessary ...
Billing for HHA Medical Supplies (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
Medical supplies are items that, due to their therapeutic or diagnostic characteristics, are essential in enabling personnel to carry out effectively the care the physician has ordered for the treatment or diagnosis of the patient's illness or injury. Medical supplies fit into two categories. They are classified as:
• Routine because ...
Institutional Provider Reporting of Service Units for DME and Supplies (Rev. 2993, Upon Implementation of ICD- 10)
By Jared Staheli | Published June 18th, 2015
Provider outpatient departments report service units using the ASC X12 837 institutional claim format or on the Form CMS 1450 the number of items being billed for orthotic and prosthetic devices.
For purchased DMEPOS items (excluding items requiring frequent and substantial servicing, capped rental items, and oxygen which cannot be purchased) ...
Billing for Total Parenteral Nutrition and Enteral Nutrition (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
All providers and suppliers billing for parenteral and enteral nutrition covered as a Part B prosthetic device benefit bill the DMERCs. Medicare pays for no more than a one-month supply of parenteral or enteral nutrients for any one prospective billing period. Claims submitted retroactively may include multiple months.
...
Billing for Total Parenteral Nutrition and Enteral Nutrition Furnished to Part B Inpatients (Rev. 2993, Upon Implementation of ICD-10)
By Jared Staheli | Published June 18th, 2015
Inpatient Part A hospital or SNF care includes total parenteral nutrition (TPN) systems and enteral nutrition (EN).
For inpatients for whom Part A benefits are not payable (e.g., benefits are exhausted or the beneficiary is entitled to Part B only), total parenteral nutrition (TPN) systems and enteral nutrition (EN) delivery systems ...
Special Considerations for SNF Billing for TPN and EN Under Part B (Rev. 2993, Upon Implementation of ICD- 10)
By Jared Staheli | Published June 18th, 2015
The HCPCS code and any appropriate modifiers are required. SNFs bill the A/B MAC (B) for TPN and EN under Part B, using the ASC X12 837 professional claim format, or the Form CMS-1500 paper claim if applicable.
The following HCPCS codes apply.
B4034 B4035 B4036 B4081 B4082 B4083 B4084 B4085 B4150 ...
Billing for Splints and Casts (Rev. 2993, Upon Implementation of ICD- 10)
By Jared Staheli | Published June 18th, 2015
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 ...
Contractor Application of Fee Schedule and Determination of Payments and Patient Liability for DME Claims (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
The following instructions apply to all contractors processing DMEPOS claims:
First the 'allowable amount' is determined. This is the lower of the fee schedule amount or the billed charge.
The application of deductible and coinsurance are calculated as follows.
A. Claims to Carriers and DMERC
Any unmet deductible is subtracted from the allowed ...
Automatic Mailing/Delivery of DMEPOS (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
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 ...
CWF Crossover Editing for DMEPOS Claims During an Inpatient Stay (Rev. 2993, Upon Implementation of ICD- 10)
By Jared Staheli | Published June 18th, 2015
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 ...
SNF Consolidated Billing and DME Provided by DMEPOS Suppliers (Rev. 222, 07-02-04)
By Jared Staheli | Published June 18th, 2015
The Social Security Act (§1861(n)) specifies that a hospital or a skilled nursing facility (SNF) cannot be considered a patient’s “home” for purposes of the DME benefit. (This restriction of coverage to only those items that are furnished for use in the patient’s home does not apply to coverage under ...
Partial Month Stays For Capped Rental Equipment (Rev. 2993, Upon Implementation of ICD- 10)
By Jared Staheli | Published June 18th, 2015
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 ...
Home Health Consolidated Billing and Supplies Provided by DMEPOS Suppliers (Rev. 2977, Upon Implementation of ICD-10)
By Jared Staheli | Published June 18th, 2015
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 ...
The DMERC systems have the capability to turn off the remit switch when sending a remittance notice is not appropriate (e.g. when the beneficiary has submitted a claim).
...
Where to Bill DMEPOS and PEN Items and Services (Rev. 1603, 10-27-08)
By Jared Staheli | Published June 17th, 2015
Skilled Nursing Facilities, CORFs, OPTs, and hospitals bill the FI for prosthetic/orthotic devices, supplies, and covered outpatient DME and oxygen (refer to §40). The HHAs may bill Durable Medical Equipment (DME) to the RHHI, or may meet the requirements of a DME supplier and bill the DME MAC. This is ...
Durable Medical Equipment (DME) (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
DME is covered under Part B as a medical or other health service (§1861(s)(6) of the Social Security Act [the Act]) and is equipment that:
a. Can withstand repeated use;
b. Is primarily and customarily used to serve a medical purpose;
c. Generally is not useful to a person in the absence of ...
Prosthetic devices (other than dental) are covered under Part B as a medical or other health service (§1861(s)(8) of the Act) and are devices that replace all or part of an internal body organ or replace all or part of the function of a permanently inoperative or malfunctioning internal body ...
Prosthetics and Orthotics (Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes) - Coverage Definition (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
These appliances are covered under Part B as a medical or other health service (§1861(s)(9) of the Act) when furnished incident to physicians' services or on a physician's order. A brace includes rigid and semi-rigid devices that are used for the purpose of supporting a weak or deformed body member ...
Section 1834(h)(1)(G) of the Act, "Replacement of Prosthetic Devices and Parts," refers to prosthetic devices that are artificial limbs. Section 1861(s) of the Act, which defines "medical and other health services," does not define artificial limbs as "prosthetic devices" (§1861(s)(8)). Rather, artificial limbs are included in the §1861(s)(9) category, "orthotics ...
Prosthetic and Orthotic Devices (P&O) (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
Except as specifically noted (e.g., IOLs), when discussing payment and other policies, instructions in this chapter will use the terms "prosthetic and orthotic devices" and the abbreviation "P&O" interchangeably to refer to both §1861(s)(8) and (9) services.
(Rev. 1, 10-01-03)
...
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 ...
Calculation and Update of Payment Rates (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
Section1834 of the Act requires the use of fee schedules under Medicare Part B for reimbursement of durable medical equipment (DME) and for prosthetic and orthotic devices, beginning January 1 1989. Payment is limited to the lower of the actual charge for the equipment or the fee established.
Beginning with fee ...
The DMEPOS fee schedule is updated annually to apply update factors and quarterly to include new codes and correct errors.
The July 2003 update of the DMEPOS fee schedule is located at http://cms.hhs.gov/manuals/pm_trans/AB03071.pdf
The October 2003 quarterly update is located at: http://cms.hhs.gov/manuals/pm_trans/AB03100.pdf
...
The fee schedule file provided by CMS contains HCPCS codes and related prices subject to the DMEPOS fee schedules, including application of any update factors and any changes to the national limited payment amounts. The file does not contain fees for drugs that are necessary for the effective use of ...
Online Pricing Files for DMEPOS (Rev. 2464, Implementation: 10-03-11)
By Jared Staheli | Published June 17th, 2015
The CMS provides updates to the DMEPOS fee schedule and related schedules annually or as otherwise necessary. Claims processing contractors must maintain at least five full calendar years of fee schedules and related pricing data (i.e., the current and four prior calendar years), regardless of the number of updates or ...
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 ...
Inexpensive or Other Routinely Purchased DME (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
For this type of equipment, contractors pay for rentals or lump-sum purchases. However, with the exception of TENS (see 30.1.2), the total payment amount may not exceed the actual charge or the fee schedule amount for purchase.
A. Inexpensive DME
This category is defined as equipment whose purchase price does ...
For payment purposes, used equipment is considered routinely purchased equipment and is any equipment that has been purchased or rented by someone before the current purchase transaction. Used equipment also includes equipment that has been used under circumstances where there has been no commercial transaction (e.g., equipment used for trial ...
In order to permit an attending physician time to determine whether the purchase of a TENS is medically appropriate for a particular patient, contractors pay 10 percent of the purchase price of the item for each of 2 months. The purchase price and payment for maintenance and servicing are determined ...
Items Requiring Frequent and Substantial Servicing (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
For this type of equipment, contractors pay the fee schedule amounts on a rental basis until medical necessity ends. Contractors cannot pay for purchase of this type of equipment.
...
The CPM devices (HCPCS code E0935) are classified as items requiring frequent and substantial servicing and are covered as DME as follows (see the Medicare National Coverage Determinations Manual.):
• Continuous passive motion devices are covered for patients who have received a total knee replacement. To qualify for coverage, use of ...
Customized items are rarely necessary and are rarely furnished. In accordance with 42 CFR Section 414.224, in order to be considered a customized item, a covered item (including a wheelchair) must be uniquely constructed or substantially modified for a specific beneficiary according to the description and orders of a physician ...
Other Prosthetic and Orthotic Devices (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
For payment purposes, these items consist of all prosthetic and orthotic devices excluding:
• items requiring frequent and substantial servicing;
• customized items;
• parenteral/enteral nutritional supplies and equipment; and
• intraocular lenses.
Other than these exceptions, contractors pay the fee schedule amounts for prosthetic and orthotic devices on a lump-sum purchase basis.
(Rev. 1, 10-01-03)
...
For these items of DME, contractors pay the fee schedule amounts on a monthly rental basis not to exceed a period of continuous use of 15 months. In the tenth month of rental, the beneficiary is given a purchase option (see §30.5.2). If the purchase option is exercised, contractors continue ...
Capped Rental Fee Variation by Month of Rental (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
For the first three rental months, the capped rental fee schedule is calculated so as to limit the monthly rental to 10 percent of the average of allowed purchase prices on assigned claims for new equipment during a base period, updated to account for inflation. For each of the remaining ...
Purchase Option for Capped Rental Items (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
Effective May 1, 1991, suppliers must give beneficiaries the option of converting their capped rental equipment to purchased equipment during their 10th continuous rental month. Contractors make no further rental payments after the 11th rental month for capped rental items until the supplier notifies the contractor that it has contacted ...
Additional Purchase Option for Electric Wheelchairs (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
Effective May 1, 1991, suppliers must give beneficiaries entitled to electric wheelchairs the option of purchasing them at the time the supplier first furnishes the item. Contractors make no rental payment for the first month for electric wheelchairs until the supplier notifies the contractor that it has given the beneficiary ...
Scenario: The Rent/Purchase Option (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
You have been renting your (specify the item(s) of equipment) for 10 continuous rental months. Medicare requires (specify name of supplier) to give you the option of converting your rental agreement to a purchase agreement. This means that if you accept this option, you would own the medical equipment. If ...
Scenario: How Medicare Pays For Electric Wheelchairs (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
If you need an electric wheelchair prescribed by your doctor, you may already know that Medicare can help pay for it. Medicare requires (specify name of supplier) to give you the option of either renting or purchasing it. If you decide that purchase is more economical, for example, because you ...
Payments for Capped Rental Items During a Period of Continuous Use (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
When no purchase options have been exercised, rental payments may not exceed a period of continuous use of longer than 15 months. For the month of death or discontinuance of use, contractors pay the full month rental. After 15 months of rental have been paid, the supplier must continue to ...
Payment for Power-Operated Vehicles that May Be Appropriately Used as Wheelchair (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
The allowed payment amount for a power-operated vehicle that may be appropriately used as wheelchair, including all medically necessary accessories, is the lowest of the:
• Actual charge for the power-operated vehicle, or
• Fee schedule amount for the power-operated vehicle.
(Rev. 1, 10-01-03)
...
For oxygen and oxygen equipment, contractors pay a monthly fee schedule amount per beneficiary. Unless otherwise noted below, the fee covers equipment, contents and supplies. Payment is not made for purchases of this type of equipment.
When an inpatient is not entitled to Part A, payment may not be made under ...
Adjustments to Monthly Oxygen Fee (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
If the prescribed amount of oxygen is less than 1 liter per minute, the fee schedule amount for stationary oxygen rental is reduced by 50 percent.
The fee schedule amount for stationary oxygen equipment is increased under the following conditions. If both conditions apply, contractors use the higher of either of ...
Where the beneficiary owns stationary liquid or gaseous oxygen equipment, the contractor pays the monthly oxygen contents fee. For owned oxygen concentrators, however, contractors do not pay a contents fee.
Where the beneficiary either owns a concentrator or does not own or rent a stationary gaseous or liquid oxygen system and ...
DMEPOS Clinical Trials and Demonstrations (Rev. 2993, Upon Implementation of ICD- 10)
By Jared Staheli | Published June 17th, 2015
The definition of the QR modifier is “item or service has been provided in a Medicare specified study.” When this modifier is attached to a HCPCS code, it generally means the service is part of a CMS related clinical trial, demonstration or study.
The DME MACs shall recognize the “QR” modifier ...
Payment for Parenteral and Enteral Nutrition (PEN) Items and Services (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
Payment for PEN items and services is made in a lump sum for nutrients and supplies that are purchased and on a monthly basis for equipment that is rented.
(Rev. 1, 10-01-03)
...
Payment for Parenteral and Enteral Pumps (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
Effective April 1, 1990, claims for rental of parenteral and enteral pumps are limited to payments for a total of 15 months during a period of medical need. Payment policies for these pumps generally follow the rules for capped rental items.
A period of medical need ends when enteral or parenteral ...
Enteral care kits contain all the necessary supplies for the enteral patient using the syringe, gravity, or pump method of nutrient administration. Parenteral nutrition care kits and their components are considered all-inclusive items necessary to administer therapy during a monthly period.
The DMERC compares the enteral feeding care kits on the ...
Payment for Home Dialysis Supplies and Equipment (Rev. 2487, 06-19-12)
By Jared Staheli | Published June 17th, 2015
For dates of service prior to January 1, 2011, there are two methods of payment for home dialysis equipment and supplies: Method I and Method II.
Under Method I, benefits are paid by a Medicare FI on the basis of a prospective payment, the composite rate. (See Chapters 8 and 12. ...
DME MAC and A/B MAC Determination of ESRD Method Selection (Rev. 2487, 06-19-12)
By Jared Staheli | Published June 17th, 2015
A. Method Selection and Form CMS-382
For services furnished prior to January 1, 2011, the beneficiary was required to complete Form CMS-382 to choose either Method I or Method II dialysis. Method I dialysis patients receive their home dialysis equipment and supplies from a dialysis facility. Method II patients chose ...
Installation and Delivery Charges for ESRD Equipment (Rev. 2487, 06-19-12)
By Jared Staheli | Published June 17th, 2015
ESRD facilities are responsible for all reasonable and necessary expenses incurred in the initial installation of home dialysis equipment, but not those expenses attributable to items that are basically for the purpose of improving the patient's home, e.g., plumbing or electrical work beyond that necessary to tie in with existing ...
Elimination of Method II Home Dialysis (Rev. 2487, 06-19-12)
By Jared Staheli | Published June 17th, 2015
Effective for dates of service on and after January 1, 2011, Section 153b of the Medicare Improvements for Patients and Providers Act (MIPPA) eliminated Method II home dialysis claims. Specifically, Method II home dialysis is no longer recognized as a beneficiary option for dates of services beginning January 1, 2011, ...
Payment of DMEPOS Items Based on Modifiers (Rev. 489, 07-05-05)
By Jared Staheli | Published June 17th, 2015
The following modifiers were added to the HCPCS to identify supplies and equipment that may be covered under more than one DMEPOS benefit category:
• AU Item furnished in conjunction with a urological, ostomy, or tracheostomy supply;
• AV Item furnished in conjunction with a prosthetic device, prosthetic or orthotic; and
• AW ...
Payment for Maintenance and Service for Non-ESRD Equipment: General (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
Contractors pay for maintenance and servicing of purchased equipment in the following classes:
• inexpensive or frequently purchased,
• customized items, other prosthetic and orthotic devices, and
• capped rental items purchased in accordance with §30.5.2 or §30.5.3.
They do not pay for maintenance and servicing of purchased items that require frequent and substantial ...
Maintenance and Service of Capped Rental Items (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
For capped rental items which have reached the 15-month rental cap, contractors pay claims for maintenance and servicing fees after six months have passed from the end of the final paid rental month or from the end of the period the item is no longer covered under the supplier's or ...
Maintenance and Service of PEN Pumps (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
Effective October 1, 1990, necessary maintenance and servicing of pumps after the 15- month rental limit is reached may include repairs and extensive maintenance that involves the breaking down of sealed components, or performing tests that require specialized testing equipment not available to the beneficiary or nursing home. The DMERC ...
Payment for Replacement of Equipment (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
Replacement of equipment which the beneficiary owns or is purchasing or is a capped rental item is covered in cases of loss, or irreparable damage or wear, and when required because of a change in the patient's condition subject to the following provisions. Expenses for replacement required because of loss ...
Payment for Replacement of Capped Rental Items (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
Effective May 1, 1991, if a capped rental item of equipment has been in continuous use by the patient, on either a rental or purchase basis, for the equipment's useful lifetime or if the item is lost or irreparably damaged, the patient may elect to obtain a new piece of ...
Intermediary Format for Durable Medical Equipment, Prosthetic, Orthotic and Supply Fee Schedule (Rev. 236, 01-03-05)
By Jared Staheli | Published June 17th, 2015
This file contains services subject to national Floors and Ceilings under the DMEPOS Fee Schedules including Surgical Dressings. RHHIs retrieve data from all DME categories contained in this file. Regular intermediaries retrieve prices for prosthetics, orthotics and surgical dressings. Also, new services that were gapped-filled by DMERCs or local Part ...
Payment for Replacement of Parenteral and Enteral Pumps (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
Payment for replacement of PEN pumps purchased more than eight years prior to the current date may be considered, with documentation that indicates proof of purchase date. Medicare will consider payment for either a replacement by purchase or 15 months of rental.
...
Payment for Replacement of Oxygen Equipment in Bankruptcy Situations (Rev. 1961, 10-04-10)
By Jared Staheli | Published June 17th, 2015
When a supplier files for Chapter 7 or 11 bankruptcy under Title 11 of the United States Code and cannot continue to furnish oxygen to its Medicare beneficiaries, the oxygen equipment is considered lost in these situations and payment may be made for replacement equipment. For replacement oxygen equipment, a ...
Payment for Delivery and Service Charges for Durable Medical Equipment (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
Delivery and service are an integral part of oxygen and durable medical equipment (DME) suppliers' costs of doing business. Such costs are ordinarily assumed to have been taken into account by suppliers (along with all other overhead expenses) in setting the prices they charge for covered items and services. As ...
Penalty Charges for Late Payment Not Included in Reasonable Charges or Fee Schedule Amounts (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
Penalty charges imposed on a beneficiary by a physician or supplier because of failure to make timely payment on a bill are not covered under Medicare.
NOTE: The Judicial Council of the American Medical Association has ruled that, "It is not in the best interest of the public or the profession ...
Payment for Additional Expenses for Deluxe Features (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
The payment amount for a given service or item, whether rented or purchased, must be consistent with what is reasonable and medically necessary to serve the intended purpose (See the Medicare Benefit Policy Manual, Chapter 15). Additional expenses for "deluxe" features, or items that are rented or purchased for aesthetic ...
Aetna Policy on Bathroom and Toilet Equipment and Supplies - Coverage
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 25th, 2015 - Last Review/Update February 18th, 2016
Clinical Policy Bulletin:Bathroom and Toilet Equipment and Supplies
Number: 0429
Policy Aetna's HMO-based and health network plans (HMO, QPOS, Health Network Only, Health Network Option, Golden Medicare, and U.S. Access) generally follow Medicare's criteria for durable medical equipment (DME) items that are used in the bathroom. Most DME items used in the bathroom are ...
Durable Medical Equipment - Documenting Continued Use
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
Treating physicians’ records often omit documentation of a beneficiary’s continuing use of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). By Medicare statute, lack of physician documentation regarding a beneficiary’s continued need and use of an item of DMEPOS will result in claim denials. Many “model charts” from various clinical ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
In the case of collagen dressings coded A6021, A6022, A6023 and A6024, the predominate component must be collagen.
Effective for claims with dates of service on or after June 1, 2013, the only products which may be billed to Medicare using code A6021, A6022, A6023 and A6024 are those for which ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have evaluated the MyoPro® upper extremity assist device and determined that it falls within the Durable Medical Equipment (DME) benefit category. Claims for MyoPro® should be submitted using the DME miscellaneous code E1399.
Suppliers are reminded that when submitting claims for items ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update August 9th, 2017
Joint DME MAC Publication
Ventilator technology has evolved to the point where it is possible to have a single device capable of operating in numerous modes, from basic continuous positive pressure (CPAP and bi-level PAP) to traditional pressure and volume ventilator modes. This creates the possibility that one piece of equipment ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update August 9th, 2017
In February 2012, The Center for Medicare and Medicaid Services (CMS) issued guidance that initially identified specific Healthcare Common Procedure Coding System (HCPCS) codes that were considered Off-the-Shelf (OTS) orthoses. The list of HCPCS codes that were finalized as part of this review as OTS orthotics, effective January 1, 2014, ...
Correct Coding: Braces (Orthoses) Attached to Wheelchairs
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update August 9th, 2017
Joint DME MAC and PDAC Publication
Recently, claims for braces attached to wheelchairs have been submitted using HCPCS code K0108 - WHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIED. K0108 is not the correct HCPCS code to use for these items.
CMS has clarified the distinction between braces (orthoses) and durable medical equipment (DME) under Medicare Part ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 24th, 2014 - Last Review/Update August 9th, 2017
The PDAC (Medicares - Pricing, Data Analysis and Coding) receives frequent inquiries regarding a billable HCPCS code and a payable HCPCS code. One may think the two are the same; however, this is not the case.
A billable HCPCS code is one that is submitted on a claim to the DME ...
Face-to-Face Encounter Compliance Requirement for Certain Durable Medical Equipment
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 9th, 2014 - Last Review/Update January 30th, 2017
On September 9, 2013, the Centers for Medicare & Medicaid Services (CMS) announced that it would begin actively enforcing and would expect full compliance with new DME face-to-face requirements on a date to be announced in Calendar Year 2014. We are publishing this announcement to make clear that the delay ...
Durable Medical Equipment, Prosthetics, Orthotics and Supplies
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 7th, 2014 - Last Review/Update January 25th, 2017
Reimbursement for most Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) is established by fee schedules. Payment is limited to the lower of the actual charge or the fee schedule amount.  We have given you some basic information to get you started including modifiers and how CMS views DMEPOS, please ...
February 12, 2015 - "DMEPOS Quality Standards" Booklet - Reminder - Released - The "DMEPOS Quality Standards" Booklet (ICN 905709) is available in downloadable format. This booklet is designed to provide education on Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS). It includes DMEPOS quality standards as well as information on Medicare deemed Accreditation Organizations (AOs) for DMEPOS suppliers.
February 12, 2015 - "Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Information for Pharmacies" Fact Sheet - Reminder - Released - The "Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Information for Pharmacies" Fact Sheet (ICN 905711) is available in downloadable format. This fact sheet is designed to provide education for pharmacies on DMEPOS. It includes information on accreditation by a CMS-approved independent national Accreditation Organization (AO) as well as information if a pharmacy wants to be considered for an exemption from the accreditation requirements.
Power Mobility Devices (PMDs): Complying with Documentation [PDF, 1MB] - This Fact Sheet (ICN 905063) is designed to provide education on Medicare coverage and billing requirements for PMDs. It includes information concerning basic coverage criteria and documentation requirements as well as, detailed coverage guidelines for the specific type of PMD provided.
Aug 15, 2014 - "DMEPOS Quality Standards" Booklet - Revised The "DMEPOS Quality Standards" Booklet (ICN 905709) was revised and is now available in downloadable format. This booklet is designed to provide education on durable medical equipment, prosthetics, orthotics and supplies (DMEPOS). It includes DMEPOS quality standards as well as information on Medicare deemed Accreditation Organizations for DMEPOS suppliers.
Aug 15, 2014 - "The Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS): Information for Pharmacies" Fact Sheet - Revised The "Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS): Information for Pharmacies" Fact Sheet (ICN 905711) was revised and is now available in downloadable format. This fact sheet is designed to provide education for pharmacies on DMEPOS. It includes information on accreditation by a CMS – approved independent national Accreditation Organization, as well as information if a pharmacy wants to be considered for an exemption from the accreditation requirements.
February 2014 - The Basics of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Accreditation [PDF, 757KB] - This fact sheet is designed to provide education on durable medical equipment, prosthetics, orthotics and supplies (DMEPOS). It includes information so suppliers can meet DMEPOS Quality Standards established by the Centers for Medicare & Medicaid Services (CMS) and become accredited by a CMS-approved independent national Accreditation Organization (AO). There is also information on the types of providers who are exempt.
Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426): Effective 01/01/2018, Durable Medical Equipment Medicare Administrative Contracts (DME MACs) have created standardized language to assist Durrable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) suppliers in understanding the information necessary to justify payment.
**Important**
The information in this document supersedes the material currently contained in all LCDs and related policy articles. Where there are differences between the policies and this article, this document shall take precedence.
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