(Medicare Claims Processing Manual)

110.1 - Billing/Claim Formats (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 DME MAC and the A/B MAC (B) are billed on the ASC X12 837 professional claim format or if permissible Form CMS -1500.  The A/B MAC (A) (including the A/B MAC (HHH)) is billed on the ASC X12 837 institutional claim format or if permissible Form CMS -1450.   Note that the ASC X12 formats support reporting of the CMNs in the FRM segment   The National Council for Prescription Drug Programs (NCPDP) Telecommunications Standard Version D0 and Batch Standard 1.2 is the HIPAA standard for electronic retail pharmacy drug claims and related coordination of benefits (COB).   This standard will be used by all DME MACs that process retail pharmacy drug transactions.  All other claims submitted to the DME MAC by pharmacies, other than retail pharmacy drug claims, must be sent in the ASC X12 837 professional claim format.   110.1.1 - Requirements for Implementing the NCPDP Standard  (Rev. 1, 10- 01-03) Retail pharmacies will be identified by a value of A5 in the specialty code as received by the National Supplier Clearinghouse.  Only DME MAC  suppliers with an A5 specialty code may use the NCPDP standard.  The DME MACs , their EDI submitters, and their other trading partners are required to transmit the NDCs in the NCPDP standards for identification of prescription drugs dispensed through a retail pharmacy.  NDCs replace the drug HCPCS codes for retail pharmacy drug transactions billed to DME MACs  via the N CPDP standards.  110.1.2 - Certificate of Medical Necessity (CMN)  (Rev. 867, Issued: 02- 17-06, Effective: 04 -01-06, Implementation: 04- 03-06)  The CMN for Parenteral Nutrition (Form CMS -852) is required.  The DME MAC  Information Form for Immunosuppressive Drugs (Form DMERC -08.02) is not required when billing for immunosuppressive drugs with dates of service on or after April 1, 2006.  As with other electronic formats, CMN data must be submitted within the valid transaction.   For claims submitted on the Form CMS -1500, retail pharmacies will continue to supply hard copy CMNs when required.   110.1.3 - NCPDP Companion Document  (Rev. 1, 10- 01-03)  The DME MACs are to provide the NCPDP companion document, found at: http://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/Downloads/NCPDPD0CG.pdf  to retail pharmacy drug claim submitters (either provider, billing agent, or clearinghouse) that will submit retail pharmacy drug claims to Medicare electronically.   110.2 - Application of DMEPOS Fee Schedule  (Rev. 1, 10- 01-03)  Services that are paid under the DME fee schedule are identified in the DMEPOS fee schedule file available free on the CMS Web Site at: http://www.cms.gov/Medicare/Medicare -Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS -Fee-Schedule.html   The DMEPOS fee schedule applies to claims to A/B MACs (A) and (HHH)  as follows.   BILL TYPE/  DEFINITION  ORTHOTICS/ PROSTHETICS  DME/  OXYGEN 12X (Hospital inpatient Part B)  Subject to fee schedule  Not covered, therefore, not subject to fee schedule  13X (Hospital Outpatient)  Subject to fee schedule  Subject to fee schedule  22X (SNF inpatient Part B)  Subject to fee schedule  Not covered, therefore, not subject to fee schedule  23X (SNF outpatient)  Subject to fee schedule  Subject to fee schedule  *32X (HHA visits under Part B Plan of Care)  Subject to fee schedule  Subject to fee schedule  *33X (HHA visits under Part A Plan of Care)  Subject to fee schedule  Subject to fee schedule  34X (HHA visits not under a Plan of Care)  Subject to fee schedule  Subject to fee schedule  71X Rural health clinics (Provider -based only)  Subject to fee schedule  Subject to fee schedule  74X (Outpatient PT)  Subject to fee schedule  Subject to fee schedule  75X (CORF)  Subject to fee schedule  Subject to fee schedule  **83X ASC  Subject to fee schedule  Subject to fee schedule  85X RPCH  Subject to fee schedule  Subject to fee schedule   * HCPCS codes A4214, A4310 through A4455, A4481, A4622, A4623, A4625, A4626, A4629, and A5051 through A5149 are excluded from the fee schedule when billed by a HHA to its A/B MAC (HHH) under these bill types.  Also, when billed on type of bill 32x or 33, c atheter and ostomy supplies are considered non- routine supplies and are billed with revenue code 027x.   ** HCPCS codes A4214, A4310 through A4330, A4338 through A4359, and A5102 through A5114 are excluded from the fee schedule when billed by a non- OPPS hospital with an ASC service under this bill type.  In addition, HCPCS codes A5119 through A5131 can be excluded or included in the fee schedule depending on the procedure in which they are associated.   NOTE:   Bill types not listed are not subject to the fee schedule for either orthotics/-prosthetics or DME/oxygen with the exception of provider -based Federally Qualified Health Centers (FQHCs).  Orthotics/prosthetics and DME/oxygen furnished by provider -based F QHCs are subject to the fee schedule.  However, bill type 73X is not reflected in the above chart since FQHCs use the bill type for the parent provider (usually 13x).  Bill types listed above are billed to the A/B MAC (A) or (HHH) for orthotics/prosthetics.   Providers other than HHAs bill the DME MAC for DME/oxygen.  HHAs bill their A/B MAC (HHH) for DME/oxygen.   DME billing is not required on Home Health PPS claims.  Home Health Agencies retain the option to bill services to A/B MAC (HHH) or have services provided under arrangements with a supplier that bills the DME MAC.   110.3 - Pre-Discharge Delivery of DMEPOS for Fitting and Training (Rev. 1, 10- 01-03) B3-3011  The following are CMS policy and billing procedures regarding the circumstances under which a supplier may deliver durable medical equipment, prosthetics, and orthotics -  but not supplies -  to a beneficiary who is in an inpatient facility that does not qualify as the beneficiary's home.   110.3.1 - Conditions That Must Be Met  (Rev. 1, 10- 01-03)  In some cases, it would be appropriate for a supplier to deliver a medically necessary item of durable medical equipment (DME), a prosthetic, or an orthotic -  but not supplies -to a beneficiary who is an inpatient in a facility that does not qualify as the  beneficiary's home.  The CMS will presume that the pre -discharge delivery of DME, a prosthetic, or an orthotic (hereafter "item") is appropriate when all the following conditions are met:   1. The item is medically necessary for use by the beneficiary in the beneficiary's home.   2. The item is medically necessary on the date of discharge, i.e., there is a physician's order with a stated initial date of need that is no later than the date of discharge for home use.  3. The supplier delivers the item to the beneficiary in the facility solely for the purpose of fitting the beneficiary for the item, or training the beneficiary in the use of the item, and the item is for subsequent use in the beneficiary's home.  4. The supplier delivers the item to the beneficiary no earlier than two days before the day the facility discharges the beneficiary.   5. The supplier ensures that the beneficiary takes the item home, or the supplier picks up the item at the facility and delivers it to the beneficiary's home on the date of discharge.  6. The reason the supplier furnishes the item is not for the purpose of eliminating the facility's responsibility to provide an item that is medically necessary for the beneficiary's use or treatment while the beneficiary is in the facility.  Such items ar e included in the Diagnostic Related Group (DRG) or Prospective Payment System (PPS) rates.  7. The supplier does not claim payment for the item for any day prior to the date of discharge.   8. The supplier does not claim payment for additional costs that the supplier incurs in ensuring that the item is delivered to the beneficiary's home on the date of discharge.  The supplier cannot bill the beneficiary for redelivery.   9. The beneficiary's discharge must be to a qualified place of service (e.g., home, custodial facility), but not to another facility (e.g., inpatient or skilled nursing) that does not qualify as the beneficiary's home.   110.3.2 - Date of Service for Pre -Discharge Delivery of DMEPOS  (Rev. 1, 10- 01-03)  For DMEPOS, the general rule is that the date of service is equal to the date of delivery.  However pre -discharge delivery of items intended for use upon discharge are considered provided on the date of discharge.  The following three scenarios demonstrate  both the latter rule (when the date of service is the date of discharge) and related exceptions.   1.  If the supplier leaves the item with the beneficiary two days prior to the date of discharge, and if the supplier, as a practical matter, need do nothing further to effect the delivery of the item to the beneficiary's home (because the beneficiary or a  caregiver takes it home), then the date of discharge is deemed to be the date of delivery of the item.  Such date must be the date of service for purposes of claims submission.  (This is not an exception to the general DMEPOS rule that the date of service must be the date of delivery.  Rather, it recognizes the supplier's responsibility -  per condition five above -  to ensure that the item is actually delivered to the beneficiary's home on the date of discharge.)  No one may bill for the days prior to the date of discharge.   2. If the supplier fits the item to the beneficiary, or trains the beneficiary in its use while the beneficiary is in the facility, but thereafter removes the item and subsequently delivers it to the beneficiary's home, then the date of service must be the  date of actual delivery of the item, provided such date is not earlier than the date of discharge.   3. If the supplier leaves the item at the facility and the beneficiary does not take the item home, or a third party does not send it to the beneficiary's home, or the supplier does not otherwise (re)deliver the item to the beneficiary's home on or before the date of discharge, the date of service must not be earlier than the actual date of delivery of the item, i.e., the actual date the item arrives, by whatever means, at the beneficiary 's home.    110.3.3 - Facility Responsibilities During the Transition Period  (Rev. 1, 10- 01-03)  1. A facility remains responsible for furnishing medically necessary items to a beneficiary for the full duration of a beneficiary's stay.  The DRG and PPS rates cover such items.   2. A facility may not delay furnishing a medically necessary item for the beneficiary's use or treatment while the beneficiary is in the facility.  A facility may not prematurely remove a medically necessary item from the beneficiary's use or treatment on the basis that a supplier delivered a similar or identical item to the beneficiary for the purpose of fitting or training.   3. A facility may not, through a stratagem of relying upon a supplier to furnish such items, improperly shift its costs for furnishing medically necessary items to a beneficiary who is a resident in the facility to Medicare Part B.   Nevertheless, beginning two days before the beneficiary's discharge, a facility may take reasonable actions to permit a supplier to fit or train the beneficiary with the medically necessary item that is for subsequent use in the beneficiary's home.  These actions may include the substitution of the supplier -furnished item, in whole or in part, for the facility-furnished item during the beneficiary's last two inpatient days provided the substitution is both reasonable and necessary for fitting or training and the item is intended for subsequent use at the beneficiary's home.   4. For prosthetic and orthotic (P&O) items, the above restrictions apply to residents in a covered Part A stay.  For DME, the above restrictions apply in a covered Part A or a Part B stay.   110.4 - Frequency of Claims for Repetitive Services (All Providers and Suppliers)  (Rev. 1, 10- 01-03)