(Medicare Claims Processing Manual)

The DME MACs process claims for items of DMEPOS for us e in the beneficiarys 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 beneficiarys home. See Pub. 100- 02, Medicare  Benefit Policy Manual, Chapter 15, 110 for more information on this benefit.  Note that the DME MACs make payment for DMEPOS only in cases where the beneficiary medically needs the equipment in his or her home.  Items provided during an inpatient hospita l or SNF stay are included in the payment made to the hospital or SNF, with certain exceptions.  (See Chapter 6, 20.3 of Pub. 100- 04, Medicare Claims Processing Manual for exceptions to SNF consolidated billing, and Chapter 20, 110.3 for exceptions to DM EPOS provided for fitting and training prior to an inpatient discharge.)  More information regarding when items of DMEPOS are billed to a DME MAC or to an A/B MAC (A) is outlined below.   For more information on jurisdiction, payment policy, and claims proc essing rules for DMEPOS, see Chapters 1 (for general information of submitting Medicare claims), 17 (for information specific to drugs paid by the DME MACs), and 20 (for information specific to DMEPOS items and services) of Pub. 100- 04, Medicare Claims Pro cessing Manual.   90.1 - Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Payment Policy (Rev. 2075, Issued: 10- 28-10, Effective: 01- 01-10, Implementation: 01- 28-11)  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.  90.1.1 - Licensure to Dispense Drugs  (Rev. 1040, Issued: 08- 25-06, E ffective: 09 -11-06, Implementation: 09- 11-06)  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 scop e of their employment. However, IHS employees are not subject to state licensure laws and IHS pharmacy departments are not licensed by individual states. IHS pharmacies are currently licensed in accordance with Federal statutes and regulations and the IHS facility is accredited in accordance with statutes and regulations. IHS pharmacy departments agree to use the IHS facilitys DEA number consistent with Federal law. Therefore, IHS pharmacies are deemed as being licensed and therefore may bill the DME MAC s for those drugs the DME MACs cover.  IHS pharmacies are considered IHS suppliers.     90.1.2 - Payment  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Surgical dressings, splints, casts, DME and other devices used for reducti ons 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 beneficiarys address.   Payment for DME MAC -covered drug claims shall be based on the ASP fee schedule  or other sources (See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 17, 20).   Payment for prosthetics and orthotics is based on the DMEPOS fee schedule by the A/B MAC (A) and DME MAC.   90.2 - DMEPOS Claims Processing Rules (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  90.2.1 - Services Billed to the DME MAC (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  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 supplie s meet the definition of this benefit and are billed to the DME MAC by IHS suppliers. See 120 of Chapter 15 of Pub. 100- 02, Medicare Benefit Policy Manual for more information on this benefit.  Claims for surgical dressings provided by IHS suppliers shall  be billed to the appropriate DME MAC. Claims for splints and casts provided by IHS suppliers should be billed to the appropriate A/B MAC (B). See 100 of Chapter 15 of Pub. 100- 02, Medicare Benefit Policy Manual for more information on this benefit.  Effective July 1, 2005, Medicare Part B payment may be made to IHS suppliers that furnish drugs covered by the DME MAC. The DME MAC drug categories are oral anti -cancer, oral anti -emetic, immunosuppressives, and drugs used for with DME, such as external infusi on pumps and nebulizers. Medicare Part B drugs incident to a physicians service shall be billed to the designated A/B MAC (B) when provided in freestanding facility. See 80, Chapter 17 of Pub. 100- 04, Medicare Claims Processing Manual for more informatio n on this benefit.   Effective July 1, 2005, Medicare Part B payment shall be made to IHS suppliers and IHS providers (including CAHs) functioning as retail pharmacies dispensing pharmaceuticals to AI/AN Medicare beneficiaries. These drugs are billed to the  appropriate DME MAC. The A/B MAC (A) shall not be billed for these drugs. Drugs dispensed for self -administration are only covered when billed to the DME MAC if also specifically covered under Medicare.   Effective July 1, 2005, Medicare Part B payment may  be made by the appropriate DME MAC to IHS suppliers that furnish therapeutic shoes and inserts for individuals with diabetes. See 140 of Chapter 15 of Pub. 100- 02, Medicare Benefit Policy Manual for more information on this benefit.   90.2.1.1 - Prostheti cs, Orthotics and Supplies Billed to the A/B MAC  (Rev. 1957; Issued:  04- 28-10; Effective Date:  01- 01-09; Implementation Date:  10 -04-10)  Effective for dates of service on or after July 1, 2005, IHS providers, including CAHs shall bill the designated A/B  MAC for prosthetics and orthotics under revenue code 0274 (prosthetic/orthotic devices) on type of bill (TOB) 12X (hospital inpatient part B), 13X (hospital outpatient) or 85X (Critical Access Hospital (CAH). Medicare Part B payment may be made to IHS pro viders that furnish prosthetic devices which replace all or part of an internal body organ (including contiguous tissue), or replace all or part of the function of a permanently inoperative or malfunctioning internal body organ. Ostomy, tracheostomy, and urological supplies meet the definition of this benefit and are billed to the A/B MAC by IHS providers.  Effective for dates of service on or after July 1, 2005, IHS providers (including CAHs) shall bill the designated A/B MAC for surgical dressings under r evenue code 0623 (surgical dressings) on TOB 12X, 13X or 85X. Splints and casts are included in the AIR for IHS providers.  Payment is made by the A/B MAC for pharmaceuticals when billed with a clinic visit. Payment is included in the AIR.   The prosthetics , orthotics and surgical dressings HCPCS codes are updated on a periodic basis and published in a Recurring Update Notification.   90.2.2 - General Claims Processing Rules for DMEPOS  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  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 processing. IHS providers already bill the designated A/B MAC (A) for DME used in the home.   The DME MACs shall identify the IHS, tribe and tribal organization facilities by specialty code.   If an IHS or an Indian tribe or tribal organization facility (hospital -based or non- hospital -based) submits an unassigned claim with dates of service on or after July 5, 2005, to the DME MAC for these Medicare Part B services, the DME MAC shall process the claim as though the IHS or an Indian tribe or tribal organization had accepted assignment of the claim.   The DME MACs shall identify DMEPOS claims submitted by IHS suppliers and waive coinsurance and deductible for these beneficiaries.   The DME MACs shall apply all ot her edits, including Certificate of Medical Necessity (CMN) requirements.   The MSN is suppressed.   Deductible and coinsurance amounts are applied by Medicare, but are waived by the IHS.   100 - A/B MAC (A)  Payment Policy and Claims Processing  (Rev. 3049, Is sued; 08 -25-14, Effective: ICD -10 - Upon Implementation of ICD -10; ASC- X12-01-01-12, Implementation: ICD -10 - Upon Implementation of ICD -10; ASC- X12 -  09-23-14)  Bills are submitted to the A/B MAC (A) by IHS providers (including CAHs) using the ASC -X12 837 institutional claim format.  In exceptional circumstances, a hardcopy Form CMS -1450 may be accepted by the designated A/B MAC (A).   The IHS providers are identified by Provider Type 08 in the Provider Specific File in the FISS claims processing system.  T he A/B MAC (A) uses specific IHS related edits, current outpatient edits for non- outpatient prospective payment system (non- OPPS) providers, and current inpatient prospective payment system (IPPS) edits on IPPS bills, as well as other edits applicable to C AHs.   Medical review is done in accordance with current procedures.  IHS provider bills are processed subject to existing CWF edits.  International Classification of Diseases -9- Clinical Modification (ICD -9-CM) codes are required on all bill types for serv ices before implementation of ICD -10.  Upon implementation of ICD -10, ICD -10-CM diagnosis codes are required on inpatient and outpatient claims, and ICD -10-PCS procedure codes are required on inpatient claims.   For services provided to AI/AN individuals in IHS providers (including CAHs) deductible and coinsurance amounts are applied by Medicare, but are waived by the IHS, and the MSN is suppressed.  Third party payers may be billed for applicable deductible and coinsurance amounts.  100.1 - A/B MAC (A) - Medicare Part B Services Paid Under Various Fee Schedules  (Rev. 2075, Issued: 10- 28-10, Effective: 01- 01-10, Implementation: 01- 28-11)  The legislative change in MMA 630 of 2003, which was effective January 1, 2005, and indefinitely extended by 2902 of the  ACA, allows IHS providers to bill for other Medicare Part B services, not covered under 1848 of the Act. In an effort to clarify that these charges are not included in the AIR (which is the general method of payment) and to allow these facilities to acqu ire the appropriate certifications, IHS providers, including CAHs were allowed to begin billing separately for the following Medicare Part B services:    Prosthetic and orthotic devices (beginning July 1, 2005);   Surgical dressings (beginning July 1, 2005);   Influenza, pneumococcal, and hepatitis B vaccines (beginning January 1, 2006); and  Ambulance services (beginning January 1, 2005).