0019 - Durable Medical Equipment Billed while Inpatient: Unbundling

Dynamic List Information
Dynamic List Data
Issue Name
0019 - Durable Medical Equipment Billed while Inpatient: Unbundling
Review Type
Automated
Provider Type
DME Physician/DME Supplier
MAC Jurisdiction
All DME MACs
Date
2017-02-01
RAC Type
Approved

Description

A supplier (includes physician furnishing DME) 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 (2) days prior to the patient's anticipated discharge to their home. The supplier should bill the date of service on the claim as the date of discharge and shall use the place of service (POS) as 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.

Affected Code(s)

E0100 -E8002; K0001 -K0899; L0112 -L4631; V2020 -V2786; A4206 -A9999; B4034 -B9999; and J and Q codes

Applicable Policy References

1.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e) - Payment of Benefits
2.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items
3.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B
4.    Social Security Act (SSA), Title XVIII, §1861(n)- Durable Medical Equipment
5.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A) - Exclusions from Coverage and Medicare as a Secondary Payer
6.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s) - Medical and Other Health Services Definitions
7.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834 (2)(B); (3)(A); (5)(A); (7)(A)(i)(1); (7)(C)(ii)(1)- Special Payment Rules for Particular Items and Services
8.    Social Security Act, Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(j) - Requirements for Suppliers of Medical Equipment and Supplies
9.    42 CFR §405.929- Post-Payment Review
10.    42 CFR §405.930- Failure to Respond to Additional Documentation Request
11.    42 Code of Federal Regulations (CFR), §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
12.    42 CF §405.986- Good Cause for Reopening
13.    42 CFR, §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 
14.    42 CFR, §414.210(f)- Payment for Replacement of Equipment
15.    42 CFR §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges
16.    42 CFR §424.57(c)- Application Certification Standards
17.    Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General
18.    Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 
19.    Medicare Claims Processing Manual, Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §10.2- Coverage Table for DME Claims, §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies
20.    Medicare Claims Processing Manual, Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §110.3.2- Date of Service for Pre-Discharge Delivery of DMEPOS
21.    Medicare Claims Processing Manual, Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §210 - CWF Crossover Editing for DMEPOS Claims During an Inpatient
22.    Medicare Claims Processing Manual, Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §211- SNF Consolidated Billing and DME Provided by DMEPOS Suppliers
23.    Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
24.    Medicare Program Integrity Manual, Chapter 4- Benefit Integrity, §4.7.3.1.2 – Exceptions
25.    Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.15 Incurred Expenses for DMEPOS
26.    CMS SNF Consolidated Billing- https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling
27.    CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426 – Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/17; Revised 01/01/2024 
28.    HCPCS level II Codebook