(Medicare Claims Processing Manual)

 accept HCPCS for all other drugs billed in the ASC X12 837 professional claim format  and paper Form CMS -1500 and   return as unprocessable claims submitted with an invalid NDC using the appropriate Remittance Advice Remark Code..   See the official Washington Publishing Company website for a current list of the Remittance Advice Remark Codes.   140.1.1 - Supplier Payment Under Medicare Part B for Insulin Furnished Through Durable Medical Equipment  (Rev. 12013; Issued: 05- 02-23; Effective: 07 -01-23; Implementation: 07 -03-23)  Section 1833(b) of the Social Security Act (the Act) is amended by Section 11407 of the Inflation Reduction Act, which waives the Medicare Part B deductible beginning July 1, 2023 for insulin furnished through an item of durable medical equipment covered under section 1861(n) of the Act. Also, Section 1833(a) of the Act is amended by Section 11407 of the Inflation Reduction Act, which requires that beneficiary coinsurance for a months supply of insulin furnished through an item of durable medical equipment  is not to exceed $35 beginning July 1, 2023. The supplier payment is to be adjusted as necessary so that Medicare pays for the rest of the amount for the months supply of insulin.   Effective July 1, 2023, to ensure the appropriate coinsurance is applied all claims billing for insulin administered through an item of DME must have a modifier appended to identify if the supply is for one month or a three month supply.  Claims submitted for insulin administered through an item of DME that do not include one of the modifiers listed below will be returned to the supplier as un- processable.   JK - Short Descriptor: Drug supply 1 month or less;  Long Descriptor: One month supply or less of drug or biological  or JL- Short Descriptor: Drug 3 month supply;  Long Descriptor: Three month supply of drug or biological    140.2 - Billing for HHA Medical Supplies  (Rev. 1, 10- 01-03) HHA- 206.4, HHA -219.1, HHA -461 (partial), HO -228.3, SNF -260.3   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 they are used in small quantities for patients during the usual course of most home visits; or    Nonroutine because they are needed to treat a patient's specific illness or injury in accordance with the physician's plan of care and meet further conditions discussed in more detail below.   Both routine and non- routine medical supplies are included in the home health PPS rate and are not separately payable if the beneficiary is under a home health plan of care.  The CMS publishes a list of these medical supplies annually, identified by HCPCS code.  If no home health plan of care is in place, non- routine medical supplies are reported separately on the bill and the supplies are payable on 34x bills.   140.3 - Billing DME MAC  for Home Dialysis Supplies and Equipment  (Rev. 1, 10- 01-03) B3-3045.7  See Chapter 8 for claims processing instructions for Method II for suppliers and DME MACs.   150 - Institutional Provider Reporting of Service Units for DME and Supplies  (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)  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) HHAs report service units using the ASC X12 837 institutional claim format or on the  Form CMS -1450 the num ber of purchased items billed.  For rental DME items, including oxygen equipment, HHAs report a separate line for each month billed indicating "1" on the ASC X12 837 institutional claim format or in the service units field on the Form CMS -1450.  For oxygen contents (HCPCS codes E0441, E0442, E0443, and E0444), the HHAs report the number of feet or pounds as described by the HCPCS code.  160 - Billing for Total Parenteral Nutrition and Enteral Nutrition  (Rev. 1, 10- 01-03) A3-3660.6   All providers and suppliers billing for parenteral and enteral nutrition covered as a Part B prosthetic device benefit bill the DME MACs.  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.   160.1 - Billing for Total Parenteral Nutrition and Enteral Nutrition Furnished to Part B Inpatients  (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)  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 are covered by Medicare as prosthetic  devices when the coverage criteria are met.  When these criteria are met, the medical equipment and medical supplies (together with nutrients) being used comprise covered prosthetic devices for coverage purposes rather than durable medical equipment.  How ever, reimbursement rules relating to DME continue to apply to such items.  When a facility supplies TPN or EN systems that meet the criteria for coverage as a prosthetic device to an inpatient whose care is not covered under Part A, the facility must bill one of the DME MACs.  Additionally, HHAs, SNFs, and hospitals that provide PEN supplies, equipment and nutrients as a prosthetic device under Part B must use the ASC X12 837 professional claim format or if permissible the Form CMS -1500 paper form to bill the appropriate DME MAC.  The DME MAC is determined according to the residen ce of the beneficiary.  Refer to 10 for jurisdiction descriptions.  A/B MACs (A) and (HHH) return claims containing PEN charges for Part B services where the bill type is 12x, 13x, 22x, 23x, 32x, 33x, or 34x with instructions to the provider to bill the DME MAC.  160.2 - Special Considerations for SNF Billing for TPN and EN Under Part B  (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)  The HCPCS code and any appropriate modifiers are required.  SNFs bill the DME MAC 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  B4151  B4152  B4153  B4154  B4155  B4156  B4164  B4168  B4172  B4176  B4178  B4180  B4184  B4186  B4189  B4193  B4197  B4199  B4216  B4220  B4222  B4224  B5000  B5100  B5200  B9000  B9002  B9004  B9006  E0776XA B9098  B9099   For SNF billing for PEN, a SNF includes the charges for PEN items it supplies beneficiaries under Part A on its Part A bill.  The services of SNF personnel who administer the PEN therapy are considered routine and are included in the basic Part A payment f or a covered stay.  SNF personnel costs to administer PEN therapy are not covered under the Part B prosthetic device benefit.   If TPN supplies, equipment and nutrients qualify as a prosthetic device and the stay is not covered by Part A, they are covered by Part B.  Part B coverage applies regardless of whether the TPN items were furnished by the SNF or an outside supplier.  The P art B TPN bill must be sent to the DME Medicare Administrative Contractor regardless of whether supplied by the SNF or an outside supplier.   Enteral nutrients provided during a stay that is covered by Part A are classified as food and included in the routine Part A payment sent to the SNF.  (See the Medicare Provider Reimbursement Manual, 2203.1E.)  Parenteral nutrient solutions provided during a covered Part A SNF stay are classified as intravenous drugs.  The SNF must bill these services as ancillary charges.  (See the Medicare Provider Reimbursement Manual, 2203.2.)   170 - Billing for Splints and Casts  (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)  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 cas t 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 in cluded 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.    180 - Billing for Home Infusion Therapy Services                                (Rev. 4112, Issued: 08- 10-18, Effective: 01 -01-19, Implementation: 01- 07-19) Effective January 1, 2019 and until the implementation of the full home infusion therapy benefit, Medicare makes separate temporary transitional payments for Home Infusion Therapy (HIT) services to eligible home infusion suppliers (i.e., a licensed pharmac y that provides external infusion pumps and external infusion pump supplies). This payment amount covers the cost of professional services, including nursing services, training and education (not otherwise paid for as durable medical equipment), remote monitoring, and monitoring services for the provision of home infusion therapy furnished by a qualified home infusion with administration of certain transitional home infusion drugs administered through an item of DME.   Temporary transitional payments are made for HIT services based on the home infusion drug provided.  Home infusion drugs are assigned to three payment categories, determined by the Healthcare Common Procedure Coding System (HCPCS) J -code.   Each DME MAC maintains a list of drugs that are administered through an item of DME and HIT payment is made for days  on which home infusion therapy services are furnished by skilled professionals in the individuals home on the day of infusion drug administration.  Temporary Transitional Payment Categories for Home Infusion Therapy Services, by Infusion Drug (J -Code)