Medicare Policies and Procedures for DMEPOS

 In Events, News
Share

This comprehensive guide provides the correct billing procedures for DMEPOS through Medicare. It also details disaster scenarios and “what if” situations, so you can stay informed and true to policy.

1. Question: If a beneficiary’s durable medical equipment, prosthetic, orthotic, or supply (DMEPOS) is lost, damaged, destroyed, or otherwise rendered unusable due to a circumstance related to an emergency, can the beneficiary obtain a replacement item, and if so, how would the supplier bill for such item?

Answer: See the Medicare Claims Processing Manual, Chapter 20, Section 50, regarding Medicare’s customary payment policy for replacement of DMEPOS. This policy is also applicable in an emergency, but the following discussion restates the policy in that context and also discusses the associated billing issues.

Except as noted below, Medicare will pay for the replacement of equipment which the beneficiary owns or is purchasing, is oxygen equipment, or is a capped rental item – when the equipment/item is lost, destroyed, irreparably damaged, or otherwise rendered unusable due to circumstances relating to an emergency declared by the President. This includes inexpensive or routinely purchased items, customized items, and other prosthetic and orthotic devices.

closeup photo of an assortment of prescription medicines

Medicare does not pay for the replacement of rented equipment (except, as noted above, oxygen equipment or capped rental items). Medicare also does not pay for replacing items that require frequent and substantial servicing. For oxygen equipment and capped rental equipment other than complex rehabilitative power wheelchairs, payment for the replacement of the equipment is made by starting a new 36 month rental period for oxygen equipment or a new 13 month rental period for capped rental equipment. Payment for replacement of complex rehabilitative power wheelchairs (K0835 thru K0864) can be made on a lump sum purchase or rental basis.

In all cases for which Medicare payment of a replaced item is available, the replacement item must be furnished by a Medicare-enrolled supplier. Moreover, a new physician’s order/certificate of medical necessity would still be required, regardless as to whether the circumstances are emergency-related or not.

The “RA” modifier is always required on the claim for a replacement item. If the beneficiary is displaced from the Federally-declared disaster/emergency area, the beneficiary may obtain the replacement item from a Medicare-enrolled supplier located outside such area. If the supplier is aware that the item is a replacement, the supplier should annotate the claim with the RA modifier.

If the beneficiary is displaced from a Federally-declared disaster/emergency area that is, or that encompasses, a competitive bidding area (CBA), and the replacement item is a competitive bid (CB) item, in addition to billing with the “RA” modifier, the out-of-CBA, Medicare-enrolled supplier must also annotate the claim with the “KT” modifier. In this circumstance, payment for the CB item will be made at the CB rate. For replacement of a standard power wheelchair (K0813 thru K0831), payment can be made on a lump sum purchase or rental basis for items furnished on or before December 31, 2013, to beneficiaries residing in a Round 1 CBA. Payment can only be made on a rental basis (i.e., starting a new 13-month rental period) for standard power wheelchairs furnished outside the nine Round 1 CBAs on or before December 31, 2013, or for any standard power wheelchair furnished in any area after December 31, 2013.

As in non-emergency circumstances, if the claim requires more than four modifiers, the supplier must include the “99” modifier on the claim to indicate to the Medicare claims administration contractor that one or more additional modifiers are applicable.

2. Question: If a beneficiary, living at home and using a stationary oxygen unit, has to be transported to another location, can Medicare pay for any portable oxygen necessary to transport the beneficiary?

Answer: Yes. Medically necessary oxygen in connection with and as part of the ambulance service would be included in Medicare’s payment to an ambulance supplier when a beneficiary is transported by ambulance and such transport is a Medicare-covered service. In addition, separate payment under Part B can be made to a DME supplier for portable oxygen when medically necessary to transport the beneficiary if the transport itself is not covered by Medicare.

3. Question: Will Medicare cover and pay for a surgical mask to prevent the spread of infectious diseases if prescribed by a physician?

Answer: No. There is no Medicare benefit category that would allow for separate coverage of a surgical mask.

4. Question: Will CMS cover the cost of a generator for medical needs?

Answer: Although a generator may be used to power durable medical equipment, it is not, nor can it be considered to be, medical equipment. By law, Medicare does not have the authority to pay for generators.

5. Question: A supplier has been dispensing portable oxygen tanks to beneficiaries per day because power is out in their area and their oxygen concentrators do not function without power. Can CMS provide reimbursement in addition to the fee schedule amount that the supplier is already receiving for that patient? That is, due to the above-normal amount being dispensed can payment be higher than the usual monthly oxygen payments? If so, would there be any particular billing requirements other than the “CR” modifier?

Answer: No, the supplier would not receive any additional payments in these situations. Medicare payment for stationary oxygen equipment, stationary oxygen contents, and portable oxygen contents is included in the supplier’s monthly fee schedule payment amount. A supplier may receive an “add on” amount as payment for portable oxygen equipment in certain situations if a beneficiary receives portable oxygen after a finding of medical need. Other than this “add on” for patients found to have a medical need for portable oxygen, the monthly payment amount for oxygen and oxygen equipment does not vary depending on the modality of oxygen that is furnished. If a beneficiary’s concentrator does not work due to a power outage, the supplier may meet the beneficiary’s stationary oxygen needs by furnishing gaseous or liquid stationary equipment until the power is back on in the beneficiary’s home.

If a supplier chooses to provide portable oxygen equipment in lieu of stationary equipment during this time, the supplier will not receive an additional Medicare payment. The supplier may also choose to pick up the concentrator while the beneficiary is using other stationary oxygen modalities.

6. Question: Can the face-to-face requirement for certain DMEPOS be waived in an emergency?

Answer: Absent an 1135 waiver, no. In the event that 1135 waivers are authorized for a particular emergency, specific waivers could be granted to waive the face-to-face requirement. Each request for such a waiver would be evaluated to determine if the particular circumstances warranted such a waiver.

7. Question: Can medical necessity documentation requirements for DMEPOS be waived in an emergency?

Answer: No. However, in a particular emergency, specific waivers could be granted to permit DME suppliers additional time to comply with medical necessity documentation requirements. But the requirement to submit such documentation cannot be waived altogether.

See the CMS’ Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.2.2, Administrative Relief in the Presence of a Disaster at: http://www.cms.gov/manuals/downloads/pim83c03.pdf

8. Question: How can people with Medicare who have been displaced, without access to their usual suppliers, get access to durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) such as wheelchairs and therapeutic shoes?

Answer: Beneficiaries who have access to a telephone may contact 1-800-Medicare for information regarding suppliers serving their current location. Alternatively, if beneficiaries have access to the Internet, they go to the following medicare.gov website to obtain a directory listing suppliers by geography, proximity, and name: http://www.medicare.gov/supplier/home.asp

9. Question: Could CMS summarize Medicare’s payment rules regarding payment for oxygen services in an emergency, especially with regard to changes in delivery modalities (portable versus stationary) made necessary by the emergency?

Answer: The Medicare monthly payment amount for oxygen and oxygen equipment includes payment for all of the different oxygen modalities (concentrator, liquid, gaseous) and also includes payment for portable oxygen contents. If there is a power outage and suppliers have to switch patients to a different modality (i.e., from the concentrator to gaseous or liquid stationary or portable equipment), the Medicare payment already factors those costs into the monthly payments. Therefore, no additional payment for switching to a different modality can be made in these situations as the Medicare payment includes payment for all modalities.

However, the monthly portable equipment add-on payment includes an additional payment (added on to the monthly payment for oxygen and oxygen equipment) when portable equipment is used and necessary. This is only an add-on payment to the monthly payment amount for oxygen and oxygen equipment and should not be confused with a monthly payment for furnishing portable oxygen equipment and oxygen contents. Again, the Medicare monthly payment for oxygen and oxygen equipment includes payment for all modalities of stationary oxygen and payment for any necessary oxygen contents, both stationary and portable oxygen contents.

Because the Medicare statute has mandated a modality-neutral payment method for oxygen since 1989, suppliers have not received increased payments or decreased payments depending on the type of system furnished except for the additional add-on payment for portable equipment.

Most suppliers have elected to furnish the least expensive modality over the years, an oxygen concentrator, but the Medicare payment is not a payment for this modality alone. Therefore, the statute would not allow an increased payment for situations where one modality is furnished as opposed to another other than the add-on payment for portable equipment.

The portable equipment add-on payment can be made in disaster situations in cases where the patient was not already using portable oxygen equipment and needs to be furnished with portable oxygen equipment during a disaster. However, if the patient was already receiving portable oxygen equipment, additional payments beyond what the supplier is already receiving for furnishing portable oxygen equipment on a monthly basis cannot be made because this amount includes the monthly payment amount and the add-on payment .

Finally, if oxygen equipment is lost as a result of a disaster, the supplier can follow the normal process for submitting a claim for replacement of the lost equipment in disaster situations. Medicare begins the 36-month payment period over in situations where lost oxygen equipment must be replaced and proper documentation describing the need for replacement and the required medical necessity documentation is furnished. The DME MACs will process the claims for replacement of lost oxygen equipment using the process established for processing disaster claims.

10. Question: Due to the limited utilities; phone, power and internet, beneficiaries have sought a secondary provider to support their respiratory needs during the state of emergency. We respectfully request CMS allow the secondary provider to bill for life-sustaining respiratory services rendered to a patient residing in the Hurricane Sandy-affected area.

Answer: The temporary supplier of oxygen and oxygen equipment needs to seek payment from the supplier that received the Medicare monthly payment amount for the remainder of the paid month during which the beneficiary relocated or needed to obtain services from an alternate supplier. The Medicare fee-for-service program does not authorize a duplicate payment for the same month. Once the month for which the initial supplier received payment is over, the alternate supplier can bill for the next continuous month, but the supplier of the equipment left behind in the patient’s home cannot be paid.

11. Question: Due to the emergency situation, patients required the use of two oxygen dispensing modalities; portable oxygen tanks and oxygen concentrator. Due to the lack of electricity, patients who typically utilize concentrators are requiring the use of cylinders until power is restored. In many cases, providers may already be billing for some form of portability code, whether it be K0738 for the filling station or the E0431 for the portable gas system. It is essential to maintain both modalities in the home environment until power is completely restored. Based upon the factors outlined, we request CMS to reimburse providers for both modalities.

Answer: If a supplier supplies liquid or gaseous cylinders in lieu of an oxygen concentrator due to a power outage, the supplier is not eligible for additional payment during this time beyond the monthly oxygen payment amount. The Medicare monthly payment amount for oxygen and oxygen equipment includes payment for all of the different oxygen modalities (concentrator, liquid and gaseous) and also includes payment for portable oxygen contents. Therefore, no additional payment for switching to a different modality can be made in these situations as the Medicare payment includes payment for all modalities.

The portable equipment add-on may be made in disaster situations in cases where the beneficiary was not already using portable equipment but now has a need for portable equipment. However, if the beneficiary was already receiving portable oxygen equipment, additional payments beyond what the supplier is already receiving for furnishing portable oxygen equipment on a monthly basis cannot be made because this amount includes the monthly payment amount and the add-on payment.Due to the beneficiary’s complex needs, requiring the use of respiratory devices from mechanical ventilators (E0450 & E0463) and Respiratory Assist Devices (RAD), a number of patients have chosen to remain at home without power. To support these life-sustaining devices requires supplemental external batteries to maintain the respiratory devices to continue to function and support the respiratory needs of the patients. Based upon the factors outlined here, we request CMS to allow providers to bill for supplemental batteries to support these devices for patients residing in the Hurricane Sandy-affected area.

Due to the beneficiary’s complex needs, requiring the use of respiratory devices from mechanical ventilators (E0450 & E0463) and Respiratory Assist Devices (RAD), a number of patients have chosen to remain at home without power. To support these life-sustaining devices requires supplemental external batteries to maintain the respiratory devices to continue to function and support the respiratory needs of the patients. Based upon the factors outlined here, we request CMS to allow providers to bill for supplemental batteries to support these devices for patients residing in the Hurricane Sandy-affected area.

MACs will process the claims for replacement of lost oxygen equipment using the process established for processing disaster claims.

12. Question: Due to the limited utilities; phone, power and internet, beneficiaries have sought a secondary provider to support their respiratory needs during the state of emergency. We respectfully request CMS allow the secondary provider to bill for life-sustaining respiratory services rendered to a patient residing in the Hurricane Sandy-affected area.

Answer: The temporary supplier of oxygen and oxygen equipment needs to seek payment from the supplier that received the Medicare monthly payment amount for the remainder of the paid month during which the beneficiary relocated or needed to obtain services from an alternate supplier. The Medicare fee-for-service program does not authorize a duplicate payment for the same month. Once the month for which the initial supplier received payment is over, the alternate supplier can bill for the next continuous month, but the supplier of the equipment left behind in the patient’s home cannot be paid.

13. Question: Due to the emergency situation, patients required the use of two oxygen dispensing modalities; portable oxygen tanks and oxygen concentrator. Due to the lack of electricity, patients who typically utilize concentrators are requiring the use of cylinders until power is restored. In many cases, providers may already be billing for some form of portability code, whether it be K0738 for the filling station or the E0431 for the portable gas system. It is essential to maintain both modalities in the home environment until power is completely restored. Based upon the factors outlined, we request CMS to reimburse providers for both modalities.

Answer: If a supplier supplies liquid or gaseous cylinders in lieu of an oxygen concentrator due to a power outage, the supplier is not eligible for additional payment during this time beyond the monthly oxygen payment amount. The Medicare monthly payment amount for oxygen and oxygen equipment includes payment for all of the different oxygen modalities (concentrator, liquid and gaseous) and also includes payment for portable oxygen contents. Therefore, no additional payment for switching to a different modality can be made in these situations as the Medicare payment includes payment for all modalities.

The portable equipment add-on may be made in disaster situations in cases where the beneficiary was not already using portable equipment but now has a need for portable equipment. However, if the beneficiary was already receiving portable oxygen equipment, additional payments beyond what the supplier is already receiving for furnishing portable oxygen equipment on a monthly basis cannot be made because this amount includes the monthly payment amount and the add-on payment.

14. Question: Due to the beneficiary’s complex needs, requiring the use of respiratory devices from mechanical ventilators (E0450 & E0463) and Respiratory Assist Devices (RAD), a number of patients have chosen to remain at home without power. To support these life-sustaining devices requires supplemental external batteries to maintain the respiratory devices to continue to function and support the respiratory needs of the patients. Based upon the factors outlined here, we request CMS to allow providers to bill for supplemental batteries to support these devices for patients residing in the Hurricane Sandy-affected area.

Answer: Medicare will pay for the replacement of accessories used in conjunction with a nebulizer, CPAP or RAD in the event that the accessories were lost, destroyed, irreparably damaged, or otherwise rendered unusable due to circumstances related to a disaster. The replacement accessories may be furnished by a new supplier if the supplier on record is unable to provide the replacement accessories to the beneficiary.

15. Question: Due to flash flooding, beneficiaries needed to leave their homes quickly and were unable to transport their hospital bed to the new location. These beneficiaries’ medical needs require the support and position from a hospital bed. Based upon the factors outlined here, we request CMS allow the provider to bill for both the primary hospital bed and the secondary temporary replacement hospital bed until the beneficiary is able to return to their home.

Answer: The temporary supplier of the hospital bed needs to seek payment from the supplier that received the Medicare monthly rental payment amount for the remainder of the paid month during which the beneficiary relocated or needed to obtain services from an alternate supplier. The Medicare fee-for-service program does not authorize a duplicate payment for the same month. Once the rental month for which the initial supplier received payment is over, the alternate supplier can bill for the next continuous month, but the supplier of the equipment left behind in the patient’s home cannot be paid.

Share
Recent Posts
Contact Us

We're not around right now. But you can send us an email and we'll get back to you, asap.

Start typing and press Enter to search

Share
photograph of an open journal at an association membership conference