(Medicare Claims Processing Manual)

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; and   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 1 st 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.   211 - SNF Consolidated Billing and DME Provided by DMEPOS Suppliers  (Rev. 222, Issued: 07- 02-04) (Effective/Implementation: Not Applicable)  211.1 - General Information  (Rev. 222, Issued: 07- 02-04) (Effective/Implementation:  Not Applicable)  The Social Security Act (1861(n)) specifies that a hospital or a skilled nursing facility (SNF) cannot be considered a patients home for purposes of the DME benefit.  (This restriction of coverage to only those items that are furnished for use in the patients home does not apply to coverage under the separate Part B benefits for Prosthetics, Orthotics, and Supplies, which are payable without regard to the particular setting in which they are furnished.)  When DME is furnished for use in a SNF during a covered Part A stay , the DME MACs shall not make separate payment for DME, since the DME is already included in the payment that the SNF receives for the covered stay itself.  When DME is furnished for use in a SNF during a noncovered stay (SNF benefits exhausted, no qualifying 3- day hospital stay, etc.), the DME MACs still shall not make separate payment for DME, as explained above, Part Bs DME benefit does not cover DME items that are furnished for use in S NFs.  Even if a patient already rents or owns a piece of DME in their home, the SNF cannot require the patient to bring their own rented or purchased DME with them into the SNF.  211.2 - Partial Month Stays For Capped Rental Equipment  (Rev. 2993, Effective: ASC X12 -  01-01-12, ICD -10 - Upon Implementation of ICD -10; Implementation: ASC X12 -  08-25-14, ICD -10 - Upon Implementation of ICD -10)  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 wh eelchair 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 beneficiarys release from the SNF.  Suppliers should annotate claims, to indicate tha t 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 t he 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 wa s 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.  212 - Home Health Consolidated Billing and Supplies Provided by DMEPOS Suppliers  (Rev.  2977, Issued; 06- 20-14, Effective: 09 -23-14; ICD- 10: Upon Implementation of ICD- 10, Implementation: 09 -23-14; ICD -10: Upon Implementation of ICD -10)  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.  For detailed information regarding home health consolidated billing, DMEPOS suppliers should refer to chapter 10, section 20 of this manual.  213- Billing for Home IVIG Items and Services  (Rev. 12437, Issued: 12- 28-23, Effective: 01 -01-24, Implementation: 01- 02-24)  Effective January 1, 2024, Medicare makes a separate bundled payment for home intravenous immune globulin (IVIG) items and services to DME suppliers. This payment amount covers the cost of nursing services and supplies including an infusion set and tubing, for the provision of IVIG administration in  the home by a DME supplier.    The items and services payment is made per visit for days on which the IVIG is administered by a nurse in the patients home. The patient must have a diagnosis of Primary Immune Deficiency Disease (PIDD) as indicated in the Intravenous Immune Globulin Poli cy Article (A5209). Payment for home IVIG items and services is only made when the patient is receiving one of the IVIG products listed on the Local Coverage Determination (LCD) for Intravenous Immune Globulin (L33610).