Article Detail - JD DME

Posted April 15, 2011

The purpose of this article is to remind suppliers that Part B DMEPOS items with service dates that overlap an inpatient hospital stay will be denied. Medicare payment is available for rental or purchase of durable medical equipment prosthetics orthotics and supplies (DMEPOS) used in a beneficiary's home. A beneficiary's home may be his/her own dwelling, an apartment, a relative's home, a home for the aged, or other type of institution. However, an institution may not be considered a beneficiary's home if it is a hospital or a skilled nursing facility (SNF). If an individual is a patient in an institution or a distinct part of an institution that meets the definition of a hospital or SNF, the individual is not entitled to have separate Part B payment made for rental or purchase of DME. This concept applies even if the patient resides in a bed or portion of the institution not certified for Medicare.

Previously, if a claim was submitted for a beneficiary and the Common Working File (CWF) identified an overlapping inpatient hospital stay, suppliers would receive ANSI denial code OA-109. However, effective for claims processed on or after April 04, 2011, suppliers could now receive either ANSI denial code OA-109 or ANSI denial code CO-97. The CO-97 denial code would be received with a remark code of M2, which states the following:

• CO-97 - The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.

• Remark Code M2 - Not paid separately when the patient is an inpatient.

This recent change will allow the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) the opportunity to deny the DMEPOS claims before they are finalized, as appropriate, to avoid future overpayments. In order to prevent this denial from occurring, suppliers should verify during the intake process and prior to delivery that the beneficiary is not in an inpatient stay.

In addition, suppliers are also reminded that in most situations the date of service submitted on the claim must match the date the DMEPOS item is delivered to the Medicare beneficiary. Medicare does make one exception to this rule. The exception is when items are provided in anticipation of discharge from a hospital or nursing facility.

A supplier may deliver a DMEPOS item to a patient in a hospital or nursing facility for the purpose of fitting or training the patient in the proper use of the item. This may be done up to two days prior to the patient's anticipated discharge to their home. The supplier shall bill the date of service on the claim as the date of discharge and shall use the place of service (POS) code 12 (patient's home). The item must be for subsequent use in the patient's home. No billing may be made for the item on those days the patient was receiving training or fitting in the hospital or nursing facility.

A supplier may also deliver a DMEPOS item to a patient's home in anticipation of a discharge from a hospital or nursing facility. The supplier may arrange for actual delivery of the item approximately two days prior to the patient's anticipated discharge to their home. The supplier shall bill the date of service on the claim as the date of discharge and should use the POS code 12 (patient's home). For additional information, please refer to the Program Integrity Manual, chapter 4, section 4.26.2 on the Centers for Medicare & Medicaid Services (CMS) Web site at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c04pdf.pdf.

The CMS requires suppliers to utilize self-service options, such as the interactive voice response (IVR) system. If a claim submitted to the Jurisdiction A DME MAC was denied due to an inpatient stay suppliers are able to obtain the admission/discharge dates and the beneficiary status via the IVR system. The name and the address of the facility are also available. In order to obtain eligibility through the IVR, suppliers can call 866-419-9458 and select option 2.

Please be advised the Jurisdiction A DME MAC Provider Contact Center may experience larger than normal call volume due to Change Request 7189. The contact center peak times are from 11:00 a.m. to 1:00 p.m. If possible, we encourage suppliers to contact us outside of this timeframe to ensure a quicker response. A customer service representative can be reached by calling 866-590-6731.