(Medicare Claims Processing Manual)

Medicare Claims Processing Manual  Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)   Table of Contents  (Rev. 12437;  Issued: 12- 28-23)  (Rev. 1 2423;  Issued: 12 -20-23)  Transmittals for Chapter 20  01 - Foreword  10 - Where to Bill DMEPOS and PEN Items and Services  10.1 -  Definitions  10.1.1 -  Durable Medical Equipment (DME)  10.1.2 -  Prosthetic Devices -  Coverage Definition 10.1.3 -  Prosthetics and Orthotics (Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes) - Coverage Definition  10.1.4 -  Payment Definition Variances  10.1.4.1 -  Prosthetic Devices  10.1.4.2 -  Prosthetic and Orthotic Devices (P&O)  10.2 -  Coverage Table for DME Claims  10.3 -  Beneficiaries Previously Enrolled in Managed Care Who Return to Traditional Fee for Service (FFS)  20 - Calculation and Update of Payment Rates  20.1 -  Update Frequency  20.2 -  Locality  20.3 -  Elimination of "Kit" Codes and Pricing of Replacement Codes  20.4 -  Contents of Fee Schedule File  20.5 -  Online Pricing Files for DMEPOS  20.6 -  Phase- in For Competitive Bid Rates in Areas Not in a Competitive Bid Area  30 - General Payment Rules  30.1 -  Inexpensive or Other Routinely Purchased DME  30.1.1 -  Used Equipment  30.1.1.2  Used Rental Equipment  30.1.2 -  Transcutaneous Electrical Nerve Stimulator (TENS)  30.2 -  Items Requiring Frequent and Substantial Servicing  30.2.1 -  Daily Payment for Continuous Passive Motion (CPM) Devices  30.3 -  Certain Customized Items  30.4 -  Other Prosthetic and Orthotic Devices  30.5 -  Capped Rental Items  30.5.1-  Capped Rental Fee Variation by Month of Rental  30.5.2 -  Purchase Option for Capped Rental Items  30.5.3 -  Additional Purchase Option for Electric Wheelchairs  30.5.3.1 -  Exhibits  30.5.4 -  Payments for Capped Rental Items During a Period of Continuous Use 30.5.5 -  Payment for Power -Operated Vehicles that May Be Appropriately Used as Wheelchair  30.6 -  Oxygen and Oxygen Equipment  30.6.1 -  Adjustments to Monthly Oxygen Fee  30.6.2 -  Purchased Oxygen Equipment  30.6.3 -  Contents Only Fee  30.6.4 -  DMEPOS Clinical Trials and Demonstrations  30.7 -  Payment for Parenteral and Enteral Nutrition (PEN) Items and Services  30.7.1 -  Payment for Parenteral and Enteral Pumps  30.7.2 -  Payment for PEN Supply Kits  30.8 -  Payment for Home Dialysis Supplies and Equipment  30.8.1 -  DME MAC and A/B MAC (A)  Determination of ESRD MethodSelection  30.8.2 -  Installation and Delivery Charges for ESRD Equipment  30.8.3 -  Elimination of Method II Home Dialysis  30.9 -  Payment of DMEPOS Items Based on Modifiers  30.9.1  Processing of Expatriate Beneficiary DMEPOS Claims for Purchased Items Submitted with the EX Modifier  40 - Payment for Maintenance and Service of Equipment  40.1 -  General  40.2 -  Maintenance and Service of Capped Rental Items  40.3 -  Maintenance and Service of PEN Pumps  50 - Payment for Replacement of Equipment  50.1 -  Payment for Replacement of Capped Rental Items  50.2 -  A/B MAC (A) or (HHH) Format for Durable Medical Equipment, Prosthetic, Orthotic and Supply Fee Schedul e 50.3 -  Payment for Replacement of Parenteral and Enteral Pumps  50.4 -  Payment for Replacement of Oxygen Equipment in Bankruptcy Situations  50.5  Payment of a Part of a DMEPOS Item  60 - Payment for Delivery and Service Charges for Durable Medical Equipment  80 - Penalty Charges for Late Payment Not Included in Reasonable Charges or Fee Schedule Amounts  90 - Payment for Additional Expenses for Deluxe Features  100 -  General Documentation Requirements  100.1 -  Written Order Prior to Delivery  100.1.1 -  Written Order Prior to Delivery -  HHAs  100.2 -  Certificates of Medical Necessity (CMN)  100.2.1 -  Completion of Certificate of Medical Necessity Forms  100.2.2 -  Evidence of Medical Necessity for Parenteral and Enteral Nutrition (PEN) Therapy  100.2.2.1 -  Scheduling and Documenting Certifications and Recertifications of Medical Necessity for PEN  100.2.2.2 -  Completion of the Elements of PEN CMN  100.2.2.3 -  DME MAC  Review of Initial PEN Certifications  100.2.3.1 -  Scheduling and Documenting Recertifications of Medical Necessity for Oxygen  100.2.3.2 -  HHA Recertification for Home Oxygen Therapy  100.2.3.3 -  A/B MAC (A) or (HHH)  Review of Oxygen Certifications  100.3 -  Limitations on DME MAC  Collection of Information 100.4 -  Reporting the Ordering/Referring NPI on Claims for DMEPOS Items Dispensed Without a Physician's Order  110 -  General Billing Requirements -  for DME, Prosthetics, Orthotic Devices, and Supplies  110.1 -  Billing/Claim Formats  110.1.1 -  Requirements for Implementing the NCPDP Standard 110.1.2 -  Certificate of Medical Necessity (CMN)  110.1.3 -  NCPDP Companion Document  110.2 -  Application of DMEPOS Fee Schedule  110.3 -  Pre-Discharge Delivery of DMEPOS for Fitting and Training 110.3.1 -  Conditions That Must Be Met  110.3.2 -  Date of Service for Pre -Discharge Delivery of DMEPOS  110.3.3 -  Facility Responsibilities During the Transition Period  110.4 -  Frequency of Claims for Repetitive  Services (All Providers and Suppliers)  110.5 -  DME MACs Only -  Appeals of Duplicate Claims  120 -  DME MACs -  Billing Procedures Related To Advanced Beneficiary Notice (ABN) Upgrades  120.1 -  Providing Upgrades of DMEPOS Without Any Extra Charge  130 -  Billing for Durable Medical Equipment (DME) and Orthotic/Prosthetic Devices  130.1 -  Provider Billing for Prosthetic and Orthotic Devices  130.2 -  Billing for Inexpensive or Other Routinely Purchased DME  130.3 -  Billing for Items Requiring Frequent and Substantial Servicing 130.4 -  Billing for Certain Customized Items  130.5 -  Billing for Capped Rental Items (Other Items of DME)  130.6 -  Billing for Oxygen and Oxygen Equipment  130.6.1 -  Oxygen Equipment and Contents Billing Chart  130.7 -  Billing for Maintenance and Servicing  (Providers and Suppliers)  130.8 -  Installment Payments  130.9 -  Showing Whether Rented or Purchased  140 -  Billing for Supplies  140.1 -  Billing for Supplies and Drugs Related to the Effective Use of DME   140.1.1 -  Billing of Insulin Furnished through DME  140.2 -  Billing for HHA Medical Supplies  140.3 -  Billing DME MAC  for Home Dialysis Supplies and Equipment  150 -  Institutional Provider Reporting of Service Units for DME and Supplies  160 -  Billing for Total Parenteral Nutrition and Enteral Nutrition  160.1 -  Billing for Total Parenteral Nutrition and Enteral Nutrition Furnished to Part B Inpatients  160.2 -  Special Considerations for SNF Billing for TPN and EN Under Part B  170 -  Billing for Splints and Casts  180 -  Billing for Home Infusion Therapy Services   181  Lymphedema Compression Treatment Benefit  190 -  A/B MAC (A), (B), (HHH), or DME MAC  Application of Fee Schedule and Determination of Payments and Patient Liability for DME Claims  200 -  Automatic Mailing/Delivery of DMEPOS  210 -  CWF Crossover Editing for DMEPOS Claims During an Inpatient Stay 211 - SNF Consolidated Billing and DME Provided by DMEPOS Suppliers  211.1 -  General Information  211.2 -  Partial Month Stays For Capped Rental Equipment  212 -  Home Health Consolidated Billing and Supplies Provided by DMEPOS Suppliers  213- Billing for Home IVIG Items and Services  220 -  Appeals  230 -  DME MAC  Systems  300 -  New Systems Requirements  01 - Foreword  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)    This chapter provides general instructions on billing and claims processing for durable medical equipment (DME), prosthetics and orthotics (P&O), parenteral and enteral nutrition (PEN), and supplies.  Coverage requirements are in the Medicare Benefit Polic y Manual and the National Coverage Determinations Manual.    These instructions are applicable to services billed to the A/B MAC (A), (B), and (HHH), and DME MAC unless otherwise noted.    The DME, prosthetic/orthotic devices (except customized devices in a SNF), supplies and oxygen used during a Part A covered stay for hospital and skilled nursing facility (SNF) inpatients are included in the inpatient prospective payment system (PPS) and a re not separately billable.    In this chapter the terms provider and supplier are used as defined in 42 CFR 400.42 CFR   400.202 (Follow the link, choose the applicable year, select Title 42, then open Chapter IV .  You then must choose which part to open.  To get to 400.202 you select the first choice and download the pdf version.).     Provider means a hospital, a CAH, a skilled nursing facility, a comprehensive outpatient rehabilitation facility, a home health agency, or a hospice that has in effect an agreement to participate in Medicare, or a clinic, a rehabilitation agency, or a publ ic health agency that has in effect a similar agreement but only to furnish outpatient physical therapy or speech -language pathology services, or a community mental health center that has in effect a similar agreement but only to furnish partial hospitaliz ation or intensive outpatient  services.    Of these provider types only hospitals, CAHs, SNFs, and HHAs would be able to bill for DMEPOS; and for hospitals, CAHs, and SNFs usually only for outpatients.  Any exceptions to this rule are discussed in this chapter.     Supplier means a physician or other practitioner, or an entity other than a provider that furnishes health care services under Medicare.    A DMEPOS supplier must meet certain requirements and enroll as described in Chapter 10 of the Program Integrity Manual.  A provider that enrolls as a supplier is considered a supplier for DMEPOS billing.  However, separate payment remains restricted to those items that are not considered included in a PPS rate.    Unless specified otherwise the instructions in this chapter apply to both providers and suppliers, and to the A/B MACs (A), (B), (HHH), and DME MACs that process their claims.