Description
All DME billed after the admit date of a patient to Hospice services and before the discharge date of a patient from Hospice services or any claims billed after the admit date of a patient to Hospice services and null discharge date (when patient status code is 30), will be denied as inclusive to Hospice services if after comparing principal diagnoses, the DME claim is related to the Hospice diagnosis. This review also excludes claims with the GW modifier.
Affected Code(s)
CMS DMEPOS Fee Schedule:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §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(dd)(1) of the Social Security Act- Hospice Care; Hospice Program
5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
7. 42 CFR §405.929- Post-Payment Review
8. 42 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
9. 42 CFR §405.986- Good Cause for Reopening
10. 42 CFR, §410.38- Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS): Scope and conditions
11. 42 CFR, §414.210(f)- Payment for Replacement of Equipment
12. 42 CFR, Section 418.202 (f), Hospice Care, Covered Services, Medical Appliances and Supplies, Including Drugs and Biologicals
13. Medicare Claims Processing Manual, Ch. 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
14. 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
15. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
16. CMS DMEPOS Fee Schedule, https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.
17. AMA CPT Codebook
18. HCPCS Level II Codebook