Before submitting a claim to the DME Medicare Administrative Contractor (MAC), a supplier must have the below on file.
- Verbal/dispensing/preliminary order - if applicable
- Five Element Order (5EO) - if applicable
- Detailed written order (DWO) - if applicable
- Certificate of Medical Necessity (CMN) - if applicable
- DME Information Form (DIF) - if applicable
- Proof of Delivery (POD)
- Beneficiary authorization
- Advance Beneficiary Notice of Noncoverage (ABN) - if applicable
- Information from treating physician concerning beneficiary's diagnosis
- Any information required for use of specific modifiers or attestation statements as defined in certain DME policies
There are numerous CMS manual requirements, reasonable and necessary (R&N) requirements, benefit category, and other statutory and regulatory requirements that must be met for payment to be justified. In the event of a claim review, a DMEPOS supplier must provide sufficient information to demonstrate that the applicable criteria have been met thus justifying payment.
Before submitting a claim to Medicare, the DME MAC supplier must have on file a dispensing order (if applicable), a DWO, a WOPD (if applicable), a CMN (if applicable), a DIF (if applicable), information from the treating physician/practitioner concerning the patient's diagnosis, and any information required for the use of specific modifiers or attestation statements as defined in certain DME MAC policies. The supplier should also obtain as much documentation from the patient's medical record to assure themselves that coverage criteria for an item have been met. If the information in the patient's medical record does not adequately support the medical necessity for the item, the supplier is liable for the dollar amount involved unless a properly executed Advance Beneficiary Notice of Noncoverage (ABN) of possible denial has been obtained.
CMS requires that in the event of an audit, the MACs, CERT, SMRC, Recovery Auditors, and ZPICs shall determine that an item/service is correctly coded. The supplier must have on file a description of items provided to the beneficiary in sufficient detail to determine the accuracy of claims coding including a description of the items(s) delivered. The description can be either a narrative description (e.g., lightweight wheelchair base), a HCPCS code, the long description of a HCPCS code, or a brand name/model number.
Documentation must be maintained in the supplier's files for seven (7) years from DOS.
If the Medicare qualifying supplier documentation is older than seven (7) years, proof of continued medical necessity of the item or necessity of the repair can be used as the supporting Medicare qualifying documentation.
Purchased Items (Including Supplies)
If, at the time of transition to Medicare, a beneficiary owns a DMEPOS item that can be purchased under the Medicare program, Medicare can pay for reasonable and necessary supplies and repairs to that item. Suppliers should review the "Beneficiary's Entering Medicare" Section of policies for directions specific to that policy if applicable. At the time of that entire item replacement, Medicare treats the claim as a new, initial claim (not as a replacement). Therefore, all coverage and documentation requirements must be met to justify reimbursement for the item. Refer to the applicable Local Coverage Determination (LCD) and related Policy Article (PA) for specific information about coverage, coding and documentation. For durable medical equipment, only certain items can be paid for on a purchase basis under the Medicare program. Medicare payment can only be made for necessary supplies and repairs of beneficiary-owned equipment that Medicare can purchase, which includes items classified under the Medicare program as inexpensive or routinely purchased items, complex rehabilitative power wheelchairs, or customized items uniquely constructed or substantially modified for a specific beneficiary. This applies in all situations, including situations where the equipment is purchased prior to Medicare eligibility.
For rental items (i.e., beneficiary does not own item at time of transition to Medicare), Medicare does not automatically assume payment for the item. Rental coverage by Medicare is treated as a new, initial claim (not as a replacement). Therefore, all coverage and documentation requirements must be met to justify reimbursement for the item. Refer to the applicable LCD and related PA for specific information about coverage, coding and documentation.
The disposition of the original item rests with the original payer, not Medicare. In addition to meeting Medicare's coverage requirements, Medicare requires that the Medicare-billed equipment be new, refurbished or inspected for functionality and ability to meet reasonable useful lifetime (RUL) requirements at the start of an initial rental.
All rented equipment must remain in good working order for the entire five year RUL of the equipment. If the equipment does not last for the entire five year RUL, the supplier must replace the equipment at no charge to Medicare or the beneficiary (42 CFR 414.210(e) (4)). When billing Medicare for the initial date of service, standard documentation requirements, including proof of delivery, apply. See CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 4, Sections 4.26 and CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.8.
- Social Security Act Sections 1833(e), 1879 and 1861(r)
- 42 CFR Section 405.841(c)(1)
- CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 20
Last Updated Jan 31, 2019