(Medicare Claims Processing Manual)

Change in Suppliers   If the beneficiary changes suppliers during or after the 15- month rental period, this does not result in a new rental episode.  For example, if the beneficiary changes suppliers after his 8th rental month, the new supplier is entitled to the monthly rental  fee for seven additional months (15 -  8).  The supplier that provides the item in the 15th month of the rental period is responsible for supplying the equipment and for maintenance and servicing after the 15- month period (see 40.2 ).  30.5.5 - Payment for Power -Operated Vehicles that May Be Appropriately Used as Wheelchair  (Rev. 1, 10- 01-03) B3-5107.1  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.   30.6 - Oxygen and Oxygen Equipment  (Rev. 11429; Issued: 05- 23-22; Effective: 09 -27-21; Implementation: 01 -03-23) For oxygen and oxygen equipment, A/B MACs (A) and (HHH), and DME MACs 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 equi pment. When an inpatient is not entitled to Part A, payment may not be made under Part B for DME or oxygen provided in a hospital or SNF.  (See the Medicare Benefit Policy Manual, Chapter 15)  Also, for outpatients using equipment or receiving oxygen in the hospital or SNF and not taking the equipment or oxygen system home, the fee schedule does not apply. There are a number of billing considerations for oxygen claims.  The chart in 130.6 indicates what amounts are payable under which situations.  Home Use of Oxygen  Effective for claims with dates of service on or after September 27, 2021, contractors shall be aware that the Centers for Medicare & Medicaid Services has reconsidered and revised National Coverage Determination (NCD) for Home Use of Oxygen (240.2). Claims for home use of oxygen and oxygen equipment must meet the coverage requirements described under Chapter 1, Section 240.2, Publication 100- 03 of the NCD Manual.  Home Oxygen Use to Treat Cluster Headache  Effective for claims between February 14, 2011 and September 26, 2021, payment for the home use of oxygen and oxygen equipment when related to the treatment of cluster headaches is covered under a National Coverage Determination (NCD).  For more informatio n, refer to chapter 1, section 240.2.2, Publication 100- 03, of the National Coverage Determinations Manual.  Effective for claims with dates of service on or after September 27, 2021, contractors shall be aware that the Centers for Medicare & Medicaid Services removed the Coverage with Evidence Development (CED) NCD for Home Oxygen Use to Treat Cluster Headache ( 240.2.2) in Chapter 1, Section 240.2.2, Publication 100- 03 of the NCD Manual. In the absence of an NCD, coverage determinations will be made by the Medicare Administrative Contractors under section 1862(a)(1)(A) of the Social Security Act, as allowed and described in Chapter 1, Section 240.2 (Home Use of Oxygen), Subsection D, of Publication 100- 03 of the NCD Manual.   30.6.1 - Adjustments to Monthly Oxygen Fee  (Rev. 1, 10- 01-03)  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, A/B MACs (A), (B), (HHH), and DME MACs use the higher of either of the following add- ons.  A/B MACs (A), (B), (HHH), and DME MACs may not pay both add- ons:  a. Volume Adjustment -  If the prescribed amount of oxygen for stationary equipment exceeds 4 liters per minute, the fee schedule amount for stationary oxygen rental is increased by 50 percent.  If the prescribed liter flow for stationary oxygen is differen t than for portable or different for rest and exercise, A/B MACs (A), (B), (HHH), and DME MACs use the prescribed amount for stationary systems and for patients at rest.  If the prescribed liter flow is different for day and night use, A/B MACs (A), (B), (HHH), and DME MACs use the average of the two rates.   b. Portable Add- on - If portable oxygen is prescribed, the fee schedule amount for portable equipment is added to the fee schedule amount for stationary oxygen rental.   30.6.2 - Purchased Oxygen Equipment  (Rev. 1, 10- 01-03)  A/B MACs (A) or (HHH), and DME MACs may not pay for oxygen equipment that is purchased on or after June 1, 1989.  30.6.3 - Contents Only Fee  (Rev. 1, 10- 01-03)  Where the beneficiary owns stationary liquid or gaseous oxygen equipment, the A/B MAC (A), (B), (HHH), or DME MAC pays the monthly oxygen contents fee.  For owned oxygen concentrators, however, A/B MAC (A), (B), (HHH), or DME MAC 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 has either rented or purchased a portable system, A/B MAC (A), (B),and   (HHH), or DME MAC pay the portable oxygen contents fee.   30.6.4 - DMEPOS Clinical Trials and Demonstrations  (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 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 when associated with an oxygen home therapy clinical trial identified by CMS and sponsored by the National Heart, Lung & Blood Institute.  DME MACs shall pay these claims if the patients arterial oxygen partial measurements are from 56 to 65 mmHg, or whose oxygen saturation is at or above 89%.  The definition of condition code 30 is qualified clinical trial.  When this condition code is reported on a claim, it generally means the service is part of a CMS related clinical trial, demonstration or study.  The A/B MACs (HHH) shall recognize condition code 30, accompanied by ICD -9-CM diagnosis code V70.7 or ICD -10 diagnosis code Z00.6, as applicable, in the second diagnosis code position, when associated with an oxygen home therapy clinical trial identified b y CMS and sponsored by the National Heart, Lung & Blood Institute.  A/B MACs (HHH) shall pay these claims if the patients arterial oxygen partial measurements are from 56 to 65 mmHg, or whose oxygen saturation is at or above 89%.   30.7 - Payment for Parenteral and Enteral Nutrition (PEN) Items and Services  (Rev. 1, 10- 01-03)  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.   30.7.1 - Payment for Parenteral and Enteral Pumps (Rev. 1, 10- 01-03) B3-5017; PM B -01-54  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 nutrients are not medically necessary for 2 consecutive months.  DME MACs do not allow additional rental payments once the 15- month limit is reached or pump is purchased unless the attending physician changes the prescription between parenteral and enteral nutrients.   DME MACs do not begin a new 15- month rental period when a patient changes suppliers.  The new supplier is entitled to the balance remaining on the 15- month rental period.  The supplier that collects the last month of rental (i.e., 15th month) is responsible for ensuring that the patient has a pump for the duration of medical necessity and for maintenance and servicing (M/S) of the pump during the duration of therapy.  A period of voluntary non- billing care and institutional care is not counted toward the 15 months.  Calculation is resumed when the voluntary care ends or when  the patient is released from institutional care.   An entire month's rent may not be paid when a patient is hospitalized during the month.  The DME MAC will request documentation to verify a break in medical need of two months or more before approving an additional 15- month rental period.   DME MACs notify the supplier of the last rental payment.  The patient has the option of purchasing or renting the pump from the supplier.  DME MACs must request written authorization from the patient before or after paying for a pump purchase.  If the patient decides to purchase the pump once rentals have been pa id, the purchase allowance will consist of the used purchase allowance less the amount allowed to date for rentals.   DME MACs provide coverage for one pump for parenteral nutrition.  DME MACs do not allow additional benefits for portable pumps or additional pumps.   30.7.2 - Payment for PEN Supply Kits  (Rev. 1, 10- 01-03)  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 adminis ter therapy during a monthly period.  The DME MAC compares the enteral feeding care kits on the claim with the method of administration indicated on the CMN.  The allowance for the amount paid for a gravity- fed care kit is paid when a pump feeding kit is billed in the absence of documentation or unacceptable documentation for a pump.  Payment is denied for additional components included as part of the PEN supply kit.   30.8 - Payment for Home Dialysis Supplies and Equipment  (Rev. 2487, Issued: 06- 08-12, Effective: 01 -01-11, Implementation: 06- 19-12)  B3-4272, B3- 4272.1 partial, A3- 3644, B3- 3045.7  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/B MAC (A) on the basis of a prospective payment, the composite rate.  (See Chapters 8 and 12. for more information on establishing the composite rate).   Under Method II, the DME MAC paid for supplies and services other than physician services.  Physician services are paid at a monthly capitation rate by the A/B MAC (B).  See Chapters 8 and 12 for more information on payment under Method II.   For dates of service on and after January 1, 2011, please refer to Section 30.8.3 for information on the elimination of Method II home dialysis.  30.8.1 - DME MAC and A/B MAC (A) Determination of ESRD Method Selection  (Rev. 2487, Issued: 06- 08-12, Effective: 01 -01-11, Implementation: 06- 19-12)  AB-01-61  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 to deal with a home dialysis supplier that is not a dialysis facility.  Once a beneficiary made a method selection choice, the beneficiary or dialysis facility submitted the Form CMS -382 to the appropriate A/B MAC (A).  The A/B M AC (A) then processed information from the form to CWF.  Chapter 8 provided the instructions for completing the form.   For dates of service prior to January 1, 2011, the  DME MACs deny Method II claims where there is no method selection or the method selection has a value of '1' on file at CWF.