Article Detail - JD DME

Original Effective Date: 08/11/2003
Revision Effective Date: 11/01/2013

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 HAO record in NSF claims, 2300 NTE and 2400 NTE for ANSI claims, or field 19 for paper claims, to indicate that the patient was in an institution, resulting in the need to establish a new anniversary date.

Example 1:

A beneficiary rents a wheelchair beginning on January 1. The Durable Medical Equipment Regional Carrier (DMERC) determines that the wheelchair is medically necessary and that the beneficiary meets all coverage criteria, and so begins to make payment on the wheelchair. The beneficiary enters a hospital on February 15 and is discharged on April 5.

In this example, Medicare will make payment for the entire month of February, because the patient was in the home for part of the month. However, the DMERC will deny the claim for March, because the patient was in a covered hospital stay for the entire month.

Because the anniversary date ("from" date) of the monthly bill was April 1, and the patient was still in the covered hospital stay on that date, the DME supplier must not submit another claim until April 5 (the date of discharge). April 5 becomes the new anniversary date ("from" date) for billing purposes, so the supplier would now bill on the 5th of the month rather than the 1st of the month for the remainder of the capped rental period.

Example 2:

A beneficiary receives oxygen on January 1. On February 28, the patient enters a hospital and is discharged on March 15.

In this example, the DMERC would deny a claim dated March 1. The supplier would submit a new claim dated March 15, which would then become the anniversary date for billing purposes.

Example 3:

A beneficiary rents a hospital bed beginning on January 1. On March 15, the patient enters a hospital and is discharged on March 25.

In this example, the DMERC will make payment for the entire month of March.

Example 4:

A beneficiary rents a wheelchair beginning December 15. On January 1, the patient enters a hospital and is discharged on January 31.

In this example, the DMERC will deny the claim dated January 15. The supplier would submit a new claim dated January 31, which would then become the anniversary date for billing purposes. The February claim would be dated February 28 because there is no 31st day in February.