Consolidated Billing - JA DME
Access the below information from this page.
- Improper Inpatient Payments
- Skilled Nursing Facility (SNF) Residents
- SNF Consolidated Billing (CB) - Capped Rental Durable Medical Equipment (DME)
- SNF Residents - Not in a Covered Part A Stay
- Home Health Prospective Payment System (PPS)
- Routine and Non-Routine Medical Supplies - CB
- DMEPOS and Hospice
- Patient Status Codes
Medicare does not pay for individual items furnished during an inpatient stay. These items are payed to the Acute Care Hospitals, Long Term Care Facilities, Inpatient Psychiatric Facilities through the Inpatient Prospective Payment System (IPPS), under Medicare Part A. The facility must furnish all inpatient services and DMEPOS items during the stay or arrange for a supplier to furnish them. If necessary, the supplier will work out a payment arrangement with the facility as they are the ones receiving reimbursement from Medicare for items provided. For additional guidance, access the "CMS Medicare DMEPOS Improper Inpatient Payments Fact Sheet" within the "Educational Resources" section of this page.
Section 4432(b) of the Balanced Budget Act (BBA) requires CB for the SNF. The CB requirement essentially confers on the SNF the Medicare billing responsibility for the entire package of care that its residents receive, except for a limited number of specifically excluded services.
For services and supplies furnished to a SNF resident covered under the Part A benefit, SNFs are not able to unbundle services to an outside provider of services or supplies that can then submit a separate bill directly to Medicare. Instead, the SNF must furnish the services or supplies either directly or under an arrangement with an outside provider. The SNF, rather than the provider of the service or supplies, bills Medicare. Medicare does not pay amounts that are due to a provider of the services or supplies to any other entity under assignment, power of attorney, or any other direct payment arrangement. (See 42 CFR 424.73) As a result, the outside supplier of the service or supplies must look to the SNF, rather than to the beneficiary or Medicare, for payment. The SNF may collect any applicable deductible or coinsurance from the beneficiary. Most covered services and supplies billed by the SNF, including those furnished under arrangement with an outside provider, for a resident of a SNF in a covered Part A stay are included in the SNF's bill to the Fiscal Intermediary (FI).
It is the supplier's responsibility to check with the facility to see if their beneficiary is a resident in a covered Part A stay. If so, all services must be billed to Medicare by the SNF except for certain excluded items. A complete list of these excluded items (listed by HCPCS may be found on the CMS SNF Consolidated Billing webpage. If a HCPCS code appears on this list, it may be billed to the DME MAC for reimbursement, even if the beneficiary is in a covered Part A SNF stay. Note: To access the list, click on the link above, select the appropriate "Part B MAC Update" (whichever year in which the service took place), and open the ZIP file found in the Downloads section. (File 1 Part A Stay Physician).
Suppliers are encouraged to check eligibility either through NMP or the IVR for SNF stays. When checking for SNF stays in the NMP, the earliest and latest billing dates, days remaining, copayment days remaining and copayment amount remaining will display. If a specific date of service is in question, enter those dates or the beneficiary's eligibility will display for the current date.
Medicare pays for DME when it is medically necessary for use in a beneficiary's home.
For capped rental items of DME where the supplier submits a monthly bill, the date of delivery on the first claim must be the "from" or anniversary date on all subsequent claims for the item.
The DME benefit is only meant for items a beneficiary is using in his or her home. For a beneficiary in a Part A covered stay, a SNF is not defined as a beneficiary's home. Medicare does not make separate payment for DME when a beneficiary is in a SNF. The SNF is expected to provide all medically necessary Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) during a beneficiary's covered Part A Stay with a few exceptions as noted above.
However, in accordance with DMEPOS payment policy, Medicare will make a separate payment for a full month of rental for DME items, provided the beneficiary was in the home on the "from" date or anniversary date defined above. Medicare will make payment for the entire month, even if the "from" date is the date of discharge from the SNF.
If a beneficiary using DME is in a covered Part A stay in a SNF for a full month, Medicare will not make payment for the DME for that month.
If the beneficiary is in a Part A covered stay, on the rental anniversary date, but not for the entire month, the discharge date becomes the new anniversary date for subsequent claims. In this situation, submit a new claim using the date of discharge as the "from" date. Note in the NTE segment/line note (Item 19 for paper claims) that the beneficiary was in a SNF, resulting in the need to establish a new anniversary date.
SNF Residents - Not in a Covered Part A Stay
Coverage consideration for DMEPOS items in a Skilled Nursing Facility (31) or a Nursing Facility (32) for beneficiaries not in a Part A covered stay is limited to the following:
- Prosthetics, orthotics and related supplies
- Urinary incontinence supplies
- Ostomy supplies
- Surgical dressings
- Oral anticancer drugs
- Oral antiemetic drugs
- Therapeutic shoes for diabetics
- Parenteral/enteral nutrition (including E0776BA, the IV pole used to administer parenteral/enteral nutrition)
- ESRD - dialysis supplies only
- Immunosuppressive drugs
Note: This list does not apply to situations in which the beneficiary is in a Part A covered SNF stay.
The Balanced Budget Act of 1997 requires consolidated billing of all home health services while a beneficiary is under a home health plan of care authorized by a physician. Consequently, billing for all such items and services will be made to a single home health agency (HHA) overseeing that plan.
The law states that payment will be made to the primary HHA whether or not the item or service was furnished by the agency, by others under arrangement to the primary agency, or when any other contracting or consulting arrangements existed with the primary agency, or "otherwise." Payment for all items is scheduled in the home health PPS episode payment that the primary HHA receives.
Types of services that are subject to the Home Health PPS include:
- Skilled nursing care;
- Home health aide services;
- Physical therapy;
- Speech-language pathology;
- Occupational therapy;
- Medical social services;
- Routine and non-routine medical supplies (see following);
- Medical services provided by an intern or resident-in-training of a hospital, under an approved teaching program of the hospital, in the case of a HHA that is affiliated or under common control with that hospital; and
- Care for homebound patients involving equipment too cumbersome to take to the home.
When a beneficiary is in a 60-day home health episode, these items are included in the PPS episode payment. HHAs must bill for all supplies provided during the 60-day episode including those not related to the plan of care because of the consolidated billing requirements. Items such as urological supplies, ostomy supplies, and surgical dressings are included in Home Health Consolidated billing and cannot be separately billed to the DME MAC.
The "Home Health Consolidated Billing Master Code List" is a list of the HCPCS codes which apply to Home Health CB. See the CMS Home Health PPS webpage.
If a HCPCS code appears on this list, it may not be billed to the DME MAC when the beneficiary is in a home health episode.
Suppliers are encouraged to check eligibility either through NMP or the IVR for these 60-day Home Health episodes. When checking the Home Health Episode History in NMP, the "payer name and ID", provider number, episode start and end date and earliest and latest billing dates will display if an episode exits within the specific date range entered. If a specific date of service is in question, enter those dates or the beneficiary's eligibility will display for the current date.
When hospice coverage is elected, the beneficiary waives all rights to Medicare Part B payments for services that are related to the treatment and management of his/her terminal illness. During any period in which the hospice benefit election is in force. All items related to the treatment and management of his/her terminal illness are paid by the intermediary. Any covered Medicare services not related to the treatment of the terminal hospice condition and which are furnished during a hospice election period, may be billed to the DME MAC for payment.
Services should be coded with the GW modifier ("service not related to the hospice patient's terminal condition"). DME MACs process services coded with the GW modifier in the normal manner for coverage and payment determinations.
Suppliers are encouraged to check eligibility either through NMP or the IVR for hospice coverage. When checking for hospice coverage in the NMP, the episode effective date, termination date and the provider number will display. If a specific date of service is in question, enter those dates or the beneficiary's eligibility will display for the current date.
- 2021 SNF Excluded Codes
- 2020 SNF Excluded Codes
- CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 20, Section 10.2 - DMEPOS and Hospice
- CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 20, Section 140.2 - Home Health PPS
- CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 20, Section 211 - SNF Residents
- Home Health Included Codes
Last Updated Thu, 18 Feb 2021 22:22:03 +0000