(Medicare Claims Processing Manual)

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.   10 - Where to Bill DMEPOS and PEN Items and Services  (Rev. 11414; Issued: 05 -12-22; Effective: 06 -13-22; Implementation: 06 -13-22) NOTE: CMS seeks to reduce burden and modernize processes to ensure a reduction in improper payments and an increase in customer satisfaction. The Certificate of Medical Necessity (CMN) form and DME Information Form (DIF) were originally required to help document  the medical necessity and other coverage criteria for selected Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items. In the past, a supplier received a signed CMN from the treating physician or created and signed a DIF to submit with the claim. Due to improvements in claims processing and medical records management, the information found on CMNs or DIFs is available either on the claim or in the medical record and is redundant. Therefore, to reduce burden and increase custom er satisfaction, providers and suppliers no longer need to submit these forms for services rendered after January 1, 2023.   For claims with dates of service on or after January 1, 2023  providers and suppliers no longer need to submit CMNs or DIFs with claims. Due to electronic filing requirements, claims received with these forms attached will be rejected and returned to the provider or supplier.   For claims with dates of service prior to January 1, 2023  processes will not change and if the CMN or DIF is required, it will still need to be submitted with the claim, or be on file with a previous claim.  This statement applies throughout the Program Integrity Manual wherever CMNs and DIFs are mentioned.   Skilled Nursing Facilities, CORFs, OPTs, and hospitals bill the A/B MAC Part A for prosthetic/orthotic devices, supplies, and covered outpatient DME and oxygen (refer to 40).  The HHAs should bill Durable Medical Equipment (DME) to the A/B MAC (HHH), or should meet the requirements of a DME supplier and bill the DME MAC.  This is the HHA's decision.  A/B MACs Part A other than A/B MACs (HHH) will receive claims only for the class "Prosthetic and Orthotic Devices."   Unless billing to the A/B MAC Part A is required as outlined in the preceding paragraph, claims for implanted DME, implanted prosthetic devices, replacement parts, accessories and supplies for the implanted DME shall be billed to the A/B MACs Part B and not the DME MAC.    Suppliers enrolled with the NSC as a DMEPOS supplier should enroll with and bill to the A/B MAC Part B for replacement parts, accessories and supplies for prosthetic implants and surgically implanted DME items that are not required to be billed to the A/B MAC Part A as stated above. Such suppliers should bill the A/B MAC Part B for these items only, unless the entity separately qualified as a supplier for items and/or services in another benefit category.   Suppliers that enroll with the NSC as a DMEPOS supplier shall bill the A/B MAC Part B using their NPI and shall not include their NSC number on the claim.   Under no circumstances should any entity that is enrolled as a DMEPOS supplier with the NSC, that is not the physician or provider that implants the device, bill the A/B MAC Part B for an implanted device. However, DMEPOS suppliers should bill for any of t he replacement parts, accessories or supplies for prosthetic implants and surgically implanted DME.   The claims filing jurisdiction for these items is determined by the suppliers location, in accordance with Pub. 100- 04, Medicare Claims Processing Manual, chapter 1, section 10. With respect to payment for these items, contractors are reminded of the long standing policy for payment of DMEPOS items, which specifies that payment for DMEPOS is based on the fee schedule amount for the State where the beneficiary maintains his/her permanent residence.    The Healthcare Common Procedure Coding System (HCPCS) codes that describe these categories of service are updated quarterly.  All  other  DMEPOS items are billed to the DME MAC.  See the Medicare Claims Processing Manual, Chapter 23, 20.3 for additional information.  A spreadsheet containing an updated list of HCPCS for which DME MACs have jurisdiction is updated as needed (typically quarterly) to reflect codes that have been added or discontinued (deleted). Any new HCPCS not included in this updated list a re A/B MAC jurisdiction only, and not DME MAC jurisdiction. The spreadsheet is  posted at the following website: https://www.cms.gov/Center/Provider -Type/Durable -Medical -Equipment -DME -Center.html under the heading of Coding.  Parenteral and enteral nutrition, and related accessories and supplies, are covered under the Medicare program as a prosthetic device.  See the Medicare Benefit Policy Manual, Chapter 15, for a description of the policy.  All Parenteral and Enteral (PEN) s ervices furnished under Part B are billed to the DME MAC.  If a provider ( see 01 ) provides PEN items under Part B it shall qualify for and receive a supplier number and bill as a supplier.  Note that some PEN items furnished to hospital and SNF inpatients are included in the Part A PPS rate and are not separately billable.  (If a serv ice is paid under Part A it should not also be paid under Part B.)    10.1 - Definitions  (Rev. 1, 10- 01-03) A3-3313.1, B3- 2100.1, HHA -220.1, HO -235.1, SNF -264.1  10.1.1 - Durable Medical Equipment (DME)  (Rev. 1, 10- 01-03)  DME is covered under Part B as a medical or other health service (1861(s)(6) of the Social Security Act [the Act]) and is equipment that:  a. Can withstand repeated use;  b. Is primarily and customarily used to serve a medical purpose;  c. Generally  is not useful to a person in the absence of an illness or injury; and  d. Is appropriate for use in the home.  All requirements of the definition must be met before an item can be considered to be durable medical equipment.  A SNF normally is not considered a beneficiary's home.  However, a  SNF can be considered a beneficiary's home for Method II home dialysis purposes.  See the Program Integrity Manual, Chapter 5, for guidelines on when a SNF may be considered a home.  For detailed coverage requirements (including definitions and discussion) associated with the following DME terms and circumstances see the Medicare Benefit Policy Manual, Chapter 15:    "Durability"  "Medical Equipment"  "Equipment Presumptively Medical"  "Equipment Presumptively Nonmedical"   "Special Exception Items"  "Necessary and Reasonable"   "Necessity for the Equipment"   "Reasonableness of the Equipment"   "Payment Consistent With What is Necessary and Reasonable"   "Beneficiary's Home"   "Establishing the Period of Medical Necessity"   "Repairs, Maintenance, Replacement and Delivery"   "Leased Renal Dialysis Equipment"   "Coverage of Supplies and Accessories"   "Beneficiary Disposal of Equipment"   "New Supplier Effective Billing Date"   "Incurred Expense Date"   "Partial Months -Monthly Payment"   "Purchased Equipment Delivered Outside the U.S."   For coverage information on specific situations and items of DME, see the Medicare National Coverage Determinations Manual.   10.1.2 - Prosthetic Devices - Coverage Definition  (Rev. 1, 10- 01-03)  Prosthetic devices (other than dental) are covered under Part B as a medical or other health service (1861(s)(8) of the Act) and are devices that replace all or part of an internal body organ or replace all or part of the function of a permanently inopera tive or malfunctioning internal body organ.  R eplacements or repairs of such devices are covered when furnished incident to physicians' services or on a physician's orders.   For detailed coverage requirements (including definitions and discussion) associated with the following prosthetic device terms and circumstances see the Medicare Benefit Policy Manual, Chapter 15:    "Test of Permanence"   "Prosthetic Lenses"   "Intraocular Lenses (IOLs)"   "Supplies, Adjustments, Repairs and Replacements"   For coverage information on specific situations and prosthetic devices, see the Medicare National Coverage Determinations Manual.   10.1.3 - Prosthetics and Orthotics (Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes) - Coverage Definition  (Rev. 1, 10- 01-03)  These appliances are covered under Part B as a medical or other health service (1861(s)(9)  of the Act) when furnished incident to physicians' services or on a physician's order.  A brace includes rigid and semi -rigid devices that are used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body.   For detailed coverage requirements (including definitions and discussion) associated with the following terms and circumstances see the Medicare Benefit Policy Manual, Chapter 15:  "Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes"   "Adjustments and Replacement of Artificial Limbs"  For coverage information on specific situations, braces, trusses, and artificial limbs and eyes, see the Medicare National Coverage Determinations Manual.   10.1.4 - Payment Definition Variances (Rev. 1, 10- 01-03)  10.1.4.1 - Prosthetic Devices  (Rev. 1, 10- 01-03)  1834(h)(1)(G)  and (H)  of the Act, "Replacement of Prosthetic Devices and Parts," refers to prosthetic devices that are artificial limbs.  (Follow the link, scroll down to section (h) and look for the above title.)  (Section 1861(s) of the Act, which defines "medical and other health services," does not define artificial limbs as "prosthetic devices" ( 1861(s)(8)  follow the link, scroll down to section (s) and look for (8) prosthetic devices).  Rather, artificial limbs are included in the 1861(s)(9) category, "orthotics and prosthetics."  When discussing replacement, these instructions will use the term "prosthetic device" as intended by 1834(h)(1)(G), i.e., artificial limbs.  10.1.4.2 - Prosthetic and Orthotic Devices (P&O)  (Rev. 1, 10- 01-03)  Except as specifically noted (e.g., IOLs), when discussing payment and other policies, instructions in this chapter will use the terms "prosthetic and orthotic devices" and the abbreviation "P&O" interchangeably to refer to both 1861(s)(8) and (9)  (follow the link, scroll down to section (s) and look for both (8) and (9)) services.   10.2 - Coverage Table for DME Claims (Rev. 4001, Issued: 03- 16-18, Effective: 06 -19-18, Implementation: 06- 19-18) B3-2105   Reimbursement may be made for expenses incurred by a patient for the rental or purchase of durable medical equipment (DME) for use in his/her home provided that all the conditions in column A below have been met.  Column B indicates the action A/B MACs (A), (B), and (HHH), and DME MACs  will take to establish that the conditions have been met.