Prostheses and Orthoses Related to a Hospital Stay

Original Effective Date: 12/06/2001
Revision Effective Date: 11/01/2013

Hospitals are required to provide whatever equipment or other items are needed by a patient during a Part A covered inpatient hospitalization. Hospitals may provide the item either directly or under arrangement with a supplier. This includes items which are provided prior to hospital admission but whose medical necessity begins during the hospital stay. One example is a custom fabricated spinal orthosis that is needed following spinal surgery. Even if this item is fabricated prior to hospital admission and is given to the patient to take to the hospital, the hospital must be the one to reimburse the orthotist for the item. In this situation, the orthotist is not permitted to submit a claim to the DMERC for that item.

Similarly, if an item is medically necessary during an inpatient stay, it must be provided and paid for by the hospital either directly or under arrangement - even if the patient will continue to use the item at home. A supplier may deliver an item to an inpatient during the two days prior to discharge to home and bill the DMERC for the item only if it is not medically necessary for the patient to use the item in the hospital. For example, if a patient needs a brace following discharge, the orthotist may come to the hospital, do any fitting or custom fabrication that is needed, and leave the brace with the patient to take home. Alternatively, a supplier may bring an item that will be needed at home to the hospital to show the patient how to use it and then leave the item with the patient to take home. If the patient does not wear or use the item in the hospital, the supplier may submit a claim to the DMERC for the item. However, if the patient wears or uses the item in the hospital - indicating that the item was a medically necessary part of treatment or rehabilitation during the hospital stay - then reimbursement is included in the hospital's payment for the inpatient admission, even if the patient will continue to use the item following discharge. When the patient wears or uses the item in the hospital, the hospital must pay the supplier for the item; the supplier may not submit a claim to the DMERC for the item.

            Last Updated Thu, 11 May 2017 12:56:08 +0000