Break in Need or Service and Break in Billing - JD DME
Break in Need or Service and Break in Billing
Break in need/service and break in billing are the most common denials when billing claims. Break in need/service and/or billing is defined as a temporary interruption in the use of equipment.
- Interruptions may last up to 60 consecutive days plus the days remaining in the rental month (this does not mean calendar month, but the 30-day rental period) in which use ceases, regardless of the reason the interruption occurs.
- Thus, if the interruption is less than 60 consecutive days plus the days remaining in the rental month in which use ceases, DME MACs will not begin a new rental period.
- Also, when an interruption continues beyond the end of the rental month in which the use ceases, MACs will not make payment for additional rentals until use of the item resumes.
- MACs will establish a new date of service when use resumes. Unpaid months of interruption do not count toward the rental month limit.
After the full rental months have been paid, the supplier must continue to provide the item without any charge, other than for the maintenance and servicing of the item (i.e., parts and labor not covered by a supplier's or manufacturer's warranty) until medical necessity ends or Medicare coverage ceases (e.g., the patient enrolls in a Health Maintenance Organization (HMO)). For this purpose, unless there is a break in need for at least 60 days, medical necessity is presumed to continue.
The scenarios below provide information on how to identify which situation your break falls under.
Break in Need/Service
A break in need or service means the same thing. This is a true break in medical need meaning the beneficiary returned the original rental equipment as they no longer medically needed the item. Break in medical need/service will require an appeal with all medical records to begin a new rental period.
More than 60 days with change in medical condition with new rental item being provided
The original rental item was returned to the supplier as the beneficiary no longer required the item (medical necessity ended). Medical need now exists with the new rental item being provided.
- Required when billing claim
- Supplier obtains new order and medical records to substantiate the medical need
- Add a narrative of BIS (break in service) or BIN (break in need) to initial claim
- Narrative must be added in loop 2400 (line note), segment NTE02 (NTE01=ADD) of ANSI X12N, version 5010A1 professional electronic claim format, or on Item 19 of paper claim form in Narrative field
- If claim denies, submit an appeal with all documentation to support medical need and indicate on appeal/redetermination explanation that there was a break in service or medical need
Break in Billing
When there is a break in billing of the claim (e.g., interruption of rental as the result of an inpatient stay, beneficiary switches suppliers, or joins a Medicare Advantage Plan), but the beneficiary continues to need/use the equipment, suppliers should continue sequential billing when the services resume, and payment resumes where it left off. The beneficiary continued to require the equipment, but during this time they may not have been using the supplier's equipment. The SNF, hospital, or Medicare Advantage Plan supplies the equipment during the time the beneficiaries are in their care.
- When the beneficiary returns home or joins Medicare fee-for-service (FFS) again, the supplier will submit a claim with the new "from" anniversary date for all subsequent claims. This new from date will be either:
- Date of discharge from the institutional provider, or
- Date eligible with Medicare
More than 60 days with no change in medical condition
- Claim requirements for billing
- Supplier obtains new order and medical records to substantiate the need
- Add a narrative to claim; BIB (break in billing)
- Narrative must be added in loop 2400 (line note), segment NTE02 (NTE01=ADD) of the ANSI X12N, version 5010A1 professional electronic claim format or on Item 19 of the paper claim form in the narrative field
- If claim denies, submit an appeal with all documentation to support medical need and indicate on appeal/redetermination that there was a break in billing
Break in Need/Service or Billing Less than 60 Days With or Without Change in Medical Condition
If the break in service/need or billing is less than 60 days, no additional action is required. The billing of the rental series will continue. The beneficiary will not qualify for a new rental period. Resume billing as normal for the rental item.