Article Detail - JA DME

Posted September 30, 2011

This article serves as clarification for the proper billing of Enteral and Parenteral Nutrition claims prospectively to ensure proper claim payments. Per Change Request 7452:

"For DMEPOS items and supplies that are provided on a recurring basis, billing must be based on prospective, not retrospective use. The following scenarios are illustrative of this concept:

Scenario 1: The treating physician writes an order for enteral nutrition which translates into the dispensing of 100 units of nutrient for one month. The supplier receives the order, delivers 100 units and bills the claim with a date of service as the date of delivery indicating 100 units. This is an example of prospective billing and is acceptable.

Scenario 2: The treating physician writes an order for enteral nutrition which translates into the dispensing of 100 units of nutrient for one month. The supplier receives the order and delivers 100 units. A claim is not billed. At the end of the month, the supplier determines that the beneficiary used 90 units for the month and delivers 90 units to replace the nutrient used. A claim is then submitted with a date of service as the date of delivery indicating 90 units of enteral nutrition. This is an example of retrospective billing and is not acceptable."

The following instructions apply to enteral and parenteral nutrition claims:

No more than one month's supply of parenteral/enteral nutrients (PEN), equipment, or supplies may be dispensed at one time. Therefore, the maximum supply that can be billed at one time is a 31-day supply.

Suppliers must not automatically dispense a quantity of items on a predetermined regular basis, even if the beneficiary has "authorized" this in advance. It is the supplier's responsibility to assess how much nutrition and supplies the beneficiary is actually using by contacting the beneficiary or caregiver prior to dispensing the items. The supplier must determine the quantities that remain from the previous delivery and modify the quantity delivered or the delivery date accordingly. If the beneficiary has not used all of their previously delivered nutrients/supplies, the supplier should either delay delivery of the next shipment or should reduce the quantity delivered so that there is no more than one month's supply on hand at any one time. This may occur in situations in which the beneficiary was admitted to the hospital, or in which the beneficiary did not receive their usual nutrient intake because of an acute illness, etc.

Contact with the beneficiary or designee regarding refills should take place no sooner than approximately 14 days prior to the delivery/shipping date. For subsequent refill deliveries, the supplier should deliver the product no sooner than 10 days prior to the end of usage for the current product. The Medicare system will allow up to a 10-day overlap in dates of service for the processing of claims for refills delivered/shipped prior to the beneficiary exhausting his/her supply. Reminder: Claims should not be consistently 10 days earlier each month as this would allow for additional payments.

The supplier itself may deliver the parenteral/enteral nutrition and supplies directly to the beneficiary or the supplier may use a shipping service to ship the items. If the supplier delivers the items directly to the beneficiary, the "From" date of service on the claim will be the actual date the items were delivered. If the supplier ships the items to the beneficiary using a shipping service, the "From" date of service will be the date the items were shipped. To determine the "To" date of service, the supplier counts the number of days the nutrients are expected to last (example: supplier ships a 28-day supply) and adds that number of days to the "From" date on the claim.

Span dates on the claim will not usually match the dates of expected use of the nutrients.

Example: Supplier used a shipping service

Month 1

• 08/04/2011: 28-day supply shipped
• 08/06/2011: Beneficiary receives supply of nutrients
• 08/07/2011: Beneficiary starts using nutrients
• 09/04/2011: Beneficiary finishes supply of nutrients in this shipment
• Dates of service on claim:
  • From date = 08/04/2011 (date the nutrients were shipped)
  • To date = 08/31/2011 (28 days after the from date since a 28-day supply was shipped)

Note: The span dates ("From" and "To" dates) are determined by the date the nutrients were shipped and the number of days for which the quantity shipped is expected to last. The span dates do not coincide with the dates the beneficiary actually used the nutrients.

Month 2

• 08/26/2011: Supplier calls beneficiary to determine beneficiary's usage during the previous month and determines quantity of next shipment
• 08/30/2011: 28-day supply of nutrients shipped to beneficiary (expected dates of use 09/05/2011 - 10/02/2011)
• 09/02/2011: Beneficiary receives shipment
• 09/05/2011: Beneficiary begins using nutrients shipped
• 09/13/2011 - 09/20/2011: Beneficiary admitted to inpatient hospital stay
• 10/09/2011: Beneficiary exhausts supply
• Dates of service on claim:
  • From date = 08/30/2011 (date the nutrients were shipped)
  • oTo date = 09/26/2011 (28 days after the "From" date since a 28-day supply was shipped)

Note: The next month's shipment should be delayed to account for the additional supplies on hand due to the inpatient hospital stay.

Shipping Supply Kits

Supply kits consist of multiple items which are sometimes shipped separately. As with nutrients, the span dates on the claim usually will not match the dates of expected use of the supplies.

Example: Supplier uses a shipping service

• 08/01/2011: 28-day supply of infusion pump bags and tubing shipped
• 08/08/2011: 28-day supply of irrigation syringes shipped
• 08/26/2011: 28-day supply of infusion pump bags and tubing shipped

Claim submission based upon above shipping example:

Month 1

• HCPCS = B4035
• Units of service = 28 UOS
• From date = 08/01/2011
• To date = 08/28/2011

Month 2

• HCPCS = B4035
• Units of service = 28 UOS
• From date = 08/26/2011
• To date = 09/23/2011

In instances where the supplies are delivered directly by the supplier, the date the beneficiary received the DMEPOS supply shall be the "From" date on the claim.

If a supplier utilizes a shipping service or mail order, suppliers shall use the shipping date as the "From" date on the claim.

Please see the following Self-Service Tools that will assist in filing PEN claims:

• Supply Refill and Contact Calculator
• Enteral Nutrition Units of Service Calculator

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