DMEPOS and Inpatient Stays - JA DME

Pre-Discharge Delivery of DMEPOS for Fitting and Training

Standard Documentation Requirements - No billing may be made for any DMEPOS to the DME MAC prior to the date of discharge from an inpatient facility. A supplier may deliver a DME, prosthetics, or orthotics item (but not supplies) to a beneficiary in an inpatient facility that does not qualify as the beneficiary’s home, for the purpose of fitting or training the beneficiary in the proper use of the item. This delivery may be done up to two (2) days prior to the beneficiary’s anticipated discharge to their home. The supplier must bill the date of service on the claim as the date of discharge and the supplier must ensure 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. Any attempt by the supplier and/or facility to substitute an item that is payable to the supplier for an item that, under statute, should be provided by the facility, may be considered fraudulent.

Note: In circumstances where the anticipated discharge date is extended, a narrative should be added to the claim to indicate the extended stay and the reason for the extension with documentation on file in the medical record to substantiate. The date of service must be the actual discharge date.

Conditions that Must be Met

In some cases, it would be appropriate for a supplier to deliver a medically necessary item of durable medical equipment, 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. Item is medically necessary for use by the beneficiary in the beneficiary's home
2. 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. 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. Supplier delivers the item to the beneficiary no earlier than two days before the day the facility discharges the beneficiary
5. 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. 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 are included in the Diagnostic Related Group (DRG) or PPS rates)
7. Supplier does not claim payment for the item for any day prior to the date of discharge
8. Supplier does not claim payment for additional costs that are incurred in ensuring that the item is delivered to the beneficiary's home on the date of discharge (beneficiary cannot be billed for redelivery)
9. Beneficiary's discharge must be to a qualified place of service, e.g., home, custodial or facility, but not to another facility (e.g., inpatient or skilled nursing) that does not qualify as the beneficiary's home

Date of Service for Pre-Discharge Delivery of DMEPOS

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.

• 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 affect 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.
• 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.
• 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.

Facility Responsibilities During Transition Period

• 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.
• 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.
• 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.
• 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.

Special Optional Requirements for Immunosuppressive Drugs

Inpatient facilities (e.g., hospitals) are responsible for providing all drugs a beneficiary needs while the beneficiary is an inpatient in the facility.

The DME MACs make payment for immunosuppressive drugs for beneficiaries who receive a covered organ transplant and who meet all other Medicare coverage criteria for immunosuppressive drugs once the beneficiary has returned to their home.

A supplier operating by mail-order may wish to put the drugs in the mail two days prior to the date a beneficiary will be discharged so the drugs will be at the beneficiary's home when they return. Under normal circumstances, the date of service listed on the claim must be the date the supplier actually delivered or mailed the item. However, under the circumstance described above, the claim processing system will, appropriately, reject the claim with a date of service listed as being prior to the patient's date of discharge because the hospital remains responsible for the provision of immunosuppressive drugs while the beneficiary is still an inpatient.

Therefore, in this situation, the pharmacy may enter the date of discharge as the date of service on the first claim it submits for the beneficiary after the beneficiary is discharged. Note that this is an optional, not mandatory, process. If the pharmacy does not want to dispense the immunosuppressive drugs prior to the beneficiary's date of discharge from the hospital, they may wait for the beneficiary to be discharged before doing so, and follow all applicable Medicare and DME MAC rules for immunosuppressive drug billing, e.g., the date of service will be the date of delivery.

Note the following conditions apply:

• The facility remains responsible for all immunosuppressive drugs required by the beneficiary for the duration of the beneficiary's inpatient stay. The pharmacy must not receive separate payment for immunosuppressive drugs prior to the date the beneficiary is discharged.
• The pharmacy must not mail or otherwise dispense the drugs any earlier than two days before the patient is discharged. It is the pharmacy's responsibility to confirm the patient's discharge date if they choose to take advantage of this option.
• The pharmacy must not submit a claim for payment prior to the beneficiary's date of discharge.
• 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 hospital or skilled nursing facility, that does not qualify as the beneficiary's home.

DMEPOS Claims During Inpatient Stay

The DMEPOS benefit is meant only for items a beneficiary is using in his or her home. For a beneficiary in a Part A inpatient stay, an institution is not defined as a beneficiary's home for DMEPOS. Medicare does not make separate payment for DMEPOS when a beneficiary is in the institution. The institution is expected to provide all medically necessary DMEPOS during a beneficiary's covered Part A stay.

However, there is an exception to the general rule above. In accordance with DMEPOS payment policy, Medicare will make a separate payment for a full month for DMEPOS items, provided the beneficiary was in the home on the "from" date or anniversary date defined below.

For DME items where the supplier submits a monthly bill, the date of delivery ("from" date) on the first claim must be the "from" or anniversary date on all subsequent claims for the item. For example, if the first claim for a wheelchair is dated September 15, all subsequent bills must be dated for the 15th of the following months (October 15, November 15, etc.).

If a beneficiary using DME is at home on the "from" date or anniversary date, Medicare will make payment for the item for the entire month, even if the "from" date is the date of discharge from the institution.

If a beneficiary using DME is in a covered Part A stay for a full month, Medicare will not make payment for the item for that month.

When the "from" date on the DMEPOS claim falls within an inpatient stay and the beneficiary returns home within the same calendar month, the supplier must submit a new claim on the date of discharge from the institutional provider and the date of discharge will become the "from" (anniversary) date for all subsequent claims.

Suppliers should annotate the note (NTE) segment for American National Standards Institute (ANSI) claims or Item 19 for paper claims to indicate the patient was in an institution, resulting in the need to establish a new anniversary date.

Resources

• CMS Internet Only Manual, Publication 100-04, Medicare Claims Processing, Chapter 20, Section 110.3
• CMS Internet Only Manual, Publication 100-02, Medicare Benefit Policy, Chapter 15, Section 110.5
• CMS Internet Only Manual, Publication 100-08, Medicare Program Integrity, Chapter 5, Section 4
• CMS Program Memorandum, Transmittal B-03-055, Change Request 2613
• Standard Documentation Requirements for All Claims Submitted to DME MACs