evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
3-5105.1  ESRD facilities are responsible for all reasonable and necessary expenses incurred in the initial installation of home dialysis equipment, but not those expenses attributable to items that are basically for the purpose of improving the patient's home, e.g., plumbing or electrical work beyond that necessary to tie in with existing power or water lines.  The delivery and installation of renal dialysis equipment, unlike that involved when a hospital bed is delivered and set up, requires testing and assurance of equipment performance. Therefore, if the supplier of home dialysis equipment customarily charges for delivery and service, and this is a common practice among other suppliers as well, this is payable.  30.8.3 - Elimination of Method II Home Dialysis  (Rev. 2487, Issued: 06- 08-12, Effective: 01 -01-11, Implementation: 06- 19-12)  Effective for dates of service on and after January 1, 2011, Section 153b of the Medicare Improvements for Patients and Providers Act (MIPPA) eliminated Method II home dialysis claims.  Specifically, Method II home dialysis is no longer recognized as a beneficiary option for dates of services beginning January 1, 2011, therefore, all ESRD patients that previously selected Method II are covered under Method I.  All home dialysis claims must be billed by an ESRD facility and paid under the ESRD PPS.  As a result, the submission of the CMS -382 form to the A/B MACs (A) or DME MACs  is no longer required for home dialysis patients on or after January 1, 2011.   Method II claims will not be accepted for dates of service on or after January 1, 2011.  Method II claims for dates of service prior to January 1, 2011 will continue to be processed within normal timely filing limitations.  For more information on timely f iling, see Pub. 100- 04, Chapter 1, Sections 70 through 70.8.6.
(Medicare Claims Processing Manual)
For dates of service on or after January 1, 2011, MACs shall continue to allow separate billing for certain ESRD supply HCPCS codes subject to the ESRD PPS consolidated billing requirements when submitted by suppliers for services not related to the benefi ciarys ESRD dialysis treatment and billed with the modifier AY.  MACs shall pay for ESRD supplies subject to ESRD CB when billed on a CMS -1500 or electronic equivalent if the ESRD supply claims contain modifier AY.  A list of equipment and supplies eligib le for separate payment when billed with modifier AY can be found in the first table (DME ESRD Supply HCPCS for ESRD PPS Consolidated Billing Edits) of the document titled Items and Services Subject to Consolidated Billing for the ESRD PPS located at the ESRD Payment website: http://www.cms.gov/ESRDPayment/50_Consolidated_Billing.asp#TopOfPage .  Some equipment and supplies are ESRD -related but are not used in other provider settings and will, therefore, never be used for reasons other than for the treatment of ESRD.  These equipment and supplies can be found listed in the second table (DME ESRD Su pply HCPCS Not Payable to DME Suppliers) of the document titled Items and Services Subject to Consolidated Billing for the ESRD PPS located at the ESRD Payment website:  http://www.cms.gov/ESRDPayment/50_Consolidated_Billing.asp#TopOfPage . DME suppliers will not be capable of billing and being paid for any of the supplies on this list using the AY modifier.   30.9  Payment of DMEPOS Items Based on Modifiers  (Rev. 3824, Issued: 08- 02-17; Effective: 07 -01-17, Implementation: 07- 03-17)  The following modifiers were added to the HCPCS to identify supplies and equipment that may be covered under more than one DMEPOS benefit category:    AU  Item furnished in conjunction with a urological, ostomy, or tracheostomy supply;   AV  Item furnished in conjunction with a prosthetic device, prosthetic or orthotic;  and  AW  Item furnished in conjunction with a surgical  dressing.
(Medicare Claims Processing Manual)
Codes A4450 and A4452 are the only codes that have been identified at this time that would require use of all three of the above listed modifiers.  Providers must report these modifiers on claims for items identified by codes A4450 and A4452 that are furni shed on or after January 1, 2005. Modifier AU may also be applicable to code A4217. Providers must report modifier AU on claims for items identified by code A4217 that are furnished in conjunction with a urological, ostomy, or tracheostomy supply on or after January 1, 2005. Items identified by code A4217 that are furnished in conjunction with durable medical equipment are reported without a modifier.  In the future, other codes may be identified as codes that must be submitted with these modifiers. Medicar e contractors base payment for the codes A4217, A4450, and A4452 on the presence or absence of these modifiers.  Codes L8040 thru L8047 describe facial prostheses. Providers must report the following modifiers on claims for replacement of these items:   KM  Replacement of facial prosthesis  including  g new impression/moulage;  and  KN  Replacement  of facial prosthesis using previous master  model.
(Medicare Claims Processing Manual)
Providers must report these modifiers on claims for replacement of items identified by codes L8040 thru L8047 that are furnished on or after January 1, 2005. Medicare contractors base payment for the codes L8040 thru L8047 on the presence of these modifier s. These modifiers are only used when the prostheses is being replaced.  In accordance with section 302(c) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), the fee schedule update factors for 2004 thru 2008 for durable medical equipment (DME), other than items designated as class III devices by the Food and Drug Administration (FDA), are equal to 0 percent. The HCPCS codes for DME designated as class III devices by the FDA are identified on the DMEPOS fee schedule available on the above mentioned web site by presence of the KF modifier.  Elevating/stair climbing power wheelchairs are class III devices. Suppliers billing the DMERCs must submit claims for the base power wheelchair portion of this device using HCPCS code K0011 (programmable power wheelchair base) with modifier KF for claims s ubmitted on or after April 1, 2004, with dates of service on or after January 1, 2004. For claims with dates of service on or after January 1, 2004, the elevation feature for this device should be billed using HCPCS code E2300 and the stair climbing featur e for this device should be billed using HCPCS code A9270. Regional home health intermediaries (RHHIs) will not be able to implement the KF modifier until January 1, 2005. Therefore, for claims with dates of service prior to January 1, 2005, HHAs must submit claims for the base power wheelchair portion of stair cl imbing wheelchairs with HCPCS code E1399. For claims with dates of service on or after January 1, 2005, HHAs must submit claims for the base power wheelchair portion of stair climbing wheelchairs with HCPCS code K0011 with modifier KF.  The fee schedule amounts for K0011 with and without the KF modifier appear on the fee schedule file referenced at www.cms.hhs.gov/providers/pufdownload/default.asp#dme . For claims with dates of service prior to January 1, 2005, RHHIs should pay claims for stair climbing
(Medicare Claims Processing Manual)
file referenced at www.cms.hhs.gov/providers/pufdownload/default.asp#dme . For claims with dates of service prior to January 1, 2005, RHHIs should pay claims for stair climbing wheelchair bases billed with code E1399 using the fee schedule amounts for K0011 with the KF modifier. All other claims for programmable power wheelchair  bases should be paid using the fee schedule amounts for K0011 without the KF modifier. Effective for claims with dates of service on or after January 1, 2005, HHAs must submit modifier KF along with the applicable HCPCS code for all DME items classified by the FDA as class III devices.  The following modifier was added to the HCPCS in 2007 as a placeholder modifier:
(Medicare Claims Processing Manual)
 KU DMEPOS Item Subject to DMEPOS Competitive Bidding Program Number  3
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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:
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
B3-5102.2.B   Replacement of equipment which the beneficiary owns or is purchasing or is a capped rental item is covered in cases of loss, or irreparable damage or wear, and when required because of a change in the patient's condition subject to the following provisions .  Expenses for replacement required because of loss or irreparable damage may be reimbursed without a physician's order when, in the DME MACs judgment, the equipment as originally ordered, considering the age of the order, still fills the patient's medic al needs.  However, claims involving replacement equipment necessitated because of wear or a change in the patient's condition must be supported by a current physician's order.  (See the Medicare  Benefit Policy Manual, Chapter 16, for payment for equipment replaced under a warranty.)  DME MACs investigate and deny cases suggesting malicious damage, culpable neglect or wrongful disposition of equipment as discussed in the Benefit Policy Manual, Chapter 15, where it is  determined that it is unreasonable to make program payment under the circumstances.  They refer such cases to the program integrity specialist in the RO.  DME MACs do not pay for replacement of rented equipment except capped rental items.  (See 50.1)  However, they pay for replacement of purchased equipment in the following classes:  inexpensive or routinely purchased, customized items, capped rental (where the beneficiary has elected to purchase the item), and other prosthetic and orthotic devices.  They do not pay for purchase or replacement of items that require frequent and substantial servicing or oxygen equipment.   50.1 - Payment for Replacement of Capped Rental Items  (Rev. 1, 10- 01-03) A3-3629