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| Prosthetics and Orthotics Ordered in a Hospital or Home Prior to a Skilled Nursing Facility Admission The Centers for Medicare and Medicaid (CMS) Services has developed policy and billing procedures regarding the circumstances under which a supplier may deliver durable medical equipment, prosthetics, and orthotics, but not supplies to a beneficiary who is in an inpatient facility that does not qualify as the beneficiary's home. The policies below outline the instances that a beneficiary enters a Skilled Nursing Facility (SNF) from their home or from an inpatient stay. The SNF Consolidated Billing (CB) provision of the Balanced Budget Act of 1997 (BBA, P.L. 105-33, Section 4432(b)) is a comprehensive billing requirement under which the SNF itself is responsible for billing Medicare for virtually all of the services that its residents receive. There are exceptions for a small number of services that are specifically excluded from this provision. These "excluded" services can be separately furnished to the resident and billed under Medicare Part B by a variety of outside sources. Included in the excluded items are customized devices. The issue arises as to who is responsible for the billing of a customized device that is ordered while a beneficiary is in an inpatient hospital stay, but the device is not delivered until after the beneficiary has transferred to a SNF. When a beneficiary is transferred from an inpatient hospital stay to a SNF Part A stay and requires an orthotic or prosthetic device, the facility where the medical need occurred is responsible for billing. If a prosthetic or orthotic device is medically necessary at the time the beneficiary is in the inpatient stay, in the rare case when the prosthetic or orthotic is not delivered until the beneficiary has arrived at the SNF, the facility remains responsible for billing for the item, not the SNF. When the medical necessity for the prosthetic or orthotic device occurs after the beneficiary is transferred from the inpatient hospital stay and enters the SNF Part A stay; the SNF is responsible for the billing of the prosthesis or orthosis. Most prosthetics (and all orthotic devices) are subject to SNF consolidated billing. The cost for the item would be covered in the SNFs global per diem payment unless the item is specifically excluded from SNF consolidated billing. A listing of excluded items from SNF consolidated billing can be located at: http://www.cms.hhs.gov/SNFConsolidatedBilling/ Certain specified customized prosthetics are excluded from the SNF consolidated billing. If the need for these devices was established while in the SNF, the supplier is to bill the durable medical equipment Medicare administrative contractor (DME MAC). When a beneficiary requires a prosthesis or orthosis while in the home and then enters a SNF for a covered Part A stay, the DME MAC should be billed by the party which supplied the device, not the SNF. Medical necessity must have been established while the beneficiary was in the home. If the beneficiary enters a SNF for a non-covered stay and thereafter develops a medical need for a customized device which the SNF orders, the SNF would bill the DME MAC for the item since SNF consolidated billing rules do not apply. In order for the SNF to bill the DME MAC for the item, they must have a valid Provider Transaction Access Number (PTAN) that was issued by the National Supplier Clearinghouse (NSC). The Centers for Medicare and Medicaid Services (CMS) will presume that the pre-discharge delivery of DME, a prosthetic, or an orthotic is appropriate when all the following conditions are met: 1. The item is medically necessary for use by the beneficiary in the beneficiary's home.2. The item is medically necessary on the date of discharge, i.e., there is a physician's order with a stated initial date of need that is no later than the date of discharge for home use.3. The supplier delivers the item to the beneficiary in the facility solely for the purpose of fitting the beneficiary for the item, or training the beneficiary in the use of the item, and the item is for subsequent use in the beneficiary's home.4. The supplier delivers the item to the beneficiary no earlier than two days before the day the facility discharges the beneficiary.5. The supplier ensures that the beneficiary takes the item home, or the supplier picks up the item at the facility and delivers it to the beneficiary's home on the date of discharge.6. The reason the supplier furnishes the item is not for the purpose of eliminating the facility's responsibility to provide an item that is medically necessary for the beneficiary's use or treatment while the beneficiary is in the facility. Such items are included in the Diagnostic Related Group (DRG) or Prospective Payment System (PPS) rates.7. The supplier does not claim payment for the item for any day prior to the date of discharge.8. The supplier does not claim payment for additional costs that the supplier incurs in ensuring that the item is delivered to the beneficiary's home on the date of discharge. The supplier cannot bill the beneficiary for redelivery.The beneficiary's discharge must be to a qualified place of service (e.g., home, custodial facility), but not to another facility (e.g., inpatient or skilled nursing) that does not qualify as the beneficiary's home.Note: For DMEPOS, the general rule is that the date of service is equal to the date of delivery. However pre-discharge delivery of items intended for use upon discharge are considered provided on the date of discharge. |
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