(Medicare Claims Processing Manual)

 KU DMEPOS Item Subject to DMEPOS Competitive Bidding Program Number  3  The DMEPOS fee schedules are updated on an annual basis in accordance with the statute and regulations. The update process for the DMEPOS fee schedule is located in Pub.100- 04, Medicare Claims Processing Manual, chapter 23, section 60. Payment on a fee sch edule basis is required for certain durable medical equipment (DME) by 1834(a) of the Social Security Act. Section1834(a)(1)(F)(ii) of the Act mandates adjustments to the fee schedule amounts for certain DME items furnished on or after January 1, 2016, including wheelchair accessories and seat and back cushions, in areas that are not competitive bid areas, based on information from  competitive bidding programs (CBPs) for DME.  Section 2 of the Patient Access and Medicare Protection Act (PAMPA) mandates that the adjusted fee schedule amounts for 2016 described above are not be applied to wheelchair accessories and seat and back cushions furnished in connection with Group 3 comple x rehabilitative power wheelchairs described by codes K0848 through K0864 of the Healthcare Common Procedure Coding System (HCPCS). Although this change is effective January 1, 2016, it is not being implemented until July 1, 2016. Until these changes are i mplemented, payment for these items will be based on the adjusted fee schedule amounts. Providers/suppliers can submit claims for these items with dates of service on or after January 1, 2016, prior to July 1, 2016, but payment will be based on the adjusted fee schedule amounts. On or after July 1, 2016, providers/suppliers can adjust previously paid claims with dates of service on or after January 1, 2016, for the corrected fee payment. Providers/suppliers must use modifier KU for claims submitted on or after July 1, 2016, with dates of service on or after January 1, 2016, and before January 1, 2017, for any HCPCS code describing a wheelchair accessory or seat or back cushion when furni shed in connection with a Group 3 complex rehabilitative power wheelchair.  Section 16005 of the 21st Century Cures Act modifies section 2(a) of the PAMPA to require that the adjusted fee schedule amounts for 2017, described in section 1834(a)(1(F)(ii) of the Act, are not to be applied to wheelchair accessories and seat and back cushions furnished in conne ction with Group 3 complex rehabilitative power wheelchairs (described by HCPCS codes K0848 through K0864) prior to July 1, 2017. Therefore, providers/suppliers should continue the use of the KU modifier on claim line items for these accessories with dates of service after June 30, 2017. Effective July 1, 2017, CMS has taken into consideration the exclusion at section 1847(a)(2)(A) of the Act to revise the policy. As a result, payment for these items furnished in connec tion with a Group 3 complex rehabilitative power wheelchair and billed with the KU modifier will be based on the unadjusted fee schedule amounts updated in accordance with section 1834(a)(14) of the Act.   30.9.1  Processing of Expatriate Beneficiary DMEPOS Claims for Purchased Items Submitted with the EX Modifier  (Rev. 3491, Issued: 04- 05-16, Effective: 07 -01-16, Implementation: 07- 05-16)  In accordance with section 1862(a)(4) of the Social Security Act, claims for DMEPOS provided to Medicare beneficiaries living outside of the U.S. are payable as long as the delivery occurred while the beneficiary was in the U.S. and the item is delivered t o a U.S. address.   Effective July 1, 2016, the modifier EX was developed to allow suppliers to bill Medicare for purchased only DMEPOS items that are furnished to expatriate beneficiaries. Suppliers should submit these claims based on their supplier locality, not based on the beneficiary address.  By attaching the EX modifier, the supplier is attesting that the beneficiary is an expatriate beneficiary, and that the item was delivered/furnished while the beneficiary is present in the U.S., and all other billing criteria has be en met.   For purchased items only furnished on or after July 1, 2016, contractors shall accept the EX modifier for processing.  Contractors shall pay claims with the EX modifier for Expatriate beneficiaries based on supplier locality.   Suppliers shall append modifier EX on all lines with a line item date of service. Contractors shall automatically deny the claim(s), when all line(s) items have not been submitted with an EX modifier.   If a beneficiary -submitted claim (1490S) is received, written attestation from the supplier must also be included.  Contractors shall deny the 1490S claim form with or without an EX modifier if a supplier 1500 claim form including the EX modifier or a writ ten supplier attestation that the beneficiary was in the U.S. when the service was rendered is not included with the 1490S.  The following items for expatriate beneficiary claims are not payable and should be denied:   Oxygen Equipment and Supplies  Parenteral and Enteral Nutrition Equipment and Supplies  Rentals -  capped or inexpensive, routinely purchased (IRP)  Contractors will apply National Mail Order (NMO) rules to expatriate claims.   NOTE:   P.O. Boxes and Lock Boxes are not allowed for NMO or any delivery of supplies for expatriate claims, and must be delivered to the beneficiary residence.   National Competitive Bid Program (CBP) rules shall apply to expatriate claims.   NOTE:  An exception for the submission of paper claims for CBP is being granted for expatriate claims.   The supplier must send paper claims to the supplier's jurisdiction for processing.  If this attestation is determined to be inaccurate, the supplier is subject to sanctions resulting from providing inaccurate information on a claim.  40 - Payment for Maintenance and Service of Equipment  (Rev. 3196, Issued: 02- 13-15, Effective: 07 -01-15, Implementation: 07- 06-15)  40.1 - General  (Rev. 3196, Issued: 02- 13-15, Effective: 07 -01-15, Implementation: 07- 06-15)  A/B MACs (HHH), and DME MACs pay for reasonable and necessary  maintenance and servicing of purchased equipment in the following classes:    inexpensive or frequently purchased,    customized items, other prosthetic and orthotic devices, and    capped rental items purchased in accordance with 30.5.2 and 30.5.3, or in situations where rental claims have been paid but title to the equipment is transferred to the beneficiary during a period of continuous use of less than 13 months.  Do not pay for maintenance and servicing of purchased items that require frequent and substantial servicing, or purchased oxygen equipment.  (Maintenance and servicing may be paid for purchased items in these two classes if they were purchased prior to June 1, 1989).  Reasonable and necessary charges include only those made for parts and labor that are not otherwise covered under a manufacturer's or supplier's warranty.  A/B MACs (A), (B), (HHH), and DME MACs pay on a lump- sum, as needed basis based on thei r individual consideration for each item.  Payment may not be made for maintenance and servicing of rented equipment other than maintenance and servicing for PEN pumps (under the conditions of 40.3), the maintenance and servicing fee established for capped rental items in 40.2, or the maintenance and servicing fee established for certain oxygen equipment in 42 CFR 414.210(e)(2) .  Servicing of equipment that a beneficiary is purchasing or already owns is covered when necessary to make the equipment serviceable.  The service charge may include the use of "loaner" equipment where this is required.  If the expense for servicing exceeds  the estimated expense of purchasing or renting another item of equipment for the remaining period of medical need, no payment can be made for the amount of the excess.  A/B MACs (HHH), and DME MACs investigate and deny cases suggesting malicious damage, culpable neglect or wrongful disposition of equipment as discussed in Pub.100-02, Medicare Benefit Policy Manual, chapter 15 where they determine that it is unreasonable to make program payment under the circumstances.  Such cases are referred to the program integrity specialist in the RO.   40.2 - Maintenance and Service of Capped Rental Items  (Rev. 3196, Issued: 02- 13-15, Effective: 07 -01-15, Implementation: 07- 06-15)  For capped rental items furnished before January 1, 2006, which have reached the 13-month rental cap, A/B MACs (HHH) and DME MACs pay claims for maintenance and servicing fees after 6 months have passed from the end of the final paid rental month or from t he end of the period the item is no longer covered under the supplier's or manufacturer's warranty, whichever is later.   The maintenance and servicing fee for capped rental items furnished before January 1, 2006, may be paid only once every 6 months.  However, in the event the beneficiary elected to purchase the equipment, maintenance and servicing are paid in accordance with the instructions in 40.1.  For capped rental items furnished on or after January 1, 2006, A/B MACs (HHH) and DME MACs shall pay for reasonable and necessary maintenance and servicing of beneficiary -owned equipment following 13 months of continuous use or, in the case of complex reha bilitative power wheelchairs, are acquired on a lump sum purchase basis.  In addition, in cases where one or more rental payments have been made for a capped rental item, and the supplier transfers title to the equipment prior to the end of a 13 month period of continuous use, A/B MACs (HHH) and DME MACs can pay for reasonable and necessary maintenance and servicing of the beneficiary -owned equipment.  40.3 - Maintenance and Service of PEN Pumps  (Rev. 1, 10- 01-03) B3-5017.4  Effective October 1, 1990, necessary maintenance  and servicing of pumps after the 15 -month rental limit is reached may include repairs and extensive maintenance that involves the breaking down of sealed components, or performing tests that require specialized testing equipment not available to the benef iciary or nursing home.  The DME MAC will pay only for actual incidents of maintenance, servicing, or replacement.  For enteral pumps, no more than one -half rental payment may be paid every six months, beginning six months after the last rental payment.  F or parenteral pumps, no more than one-half the rental payment may be paid every three months, beginning three months after the last rental payment for the pump.  The DME MAC requests written proof from the supplier of maintenance and servicing of the pump.   50 - Payment for Replacement of Equipment  (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.   B3-5102.2.B