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Durable Medical Equipment

Medicare Internet-Only Manuals

DMEPOS Claims Processing Manual
DME Benefit Policy Manual - Medicare Benefit Policy Manual, Chapter 15 (Covered Medical and Other Health Services), Section 110 (Durable Medical Equipment)

CMSDME Center -- http://www.cms.hhs.gov/center/dme.asp

Definition of DME: (Medicare Pub 100-2 Benefit Policy Manual, Chapter 15 - Covered Medical and Other Health Services, Section 110.1 - Definition of DME, and Medicare Pub 100-4 Claims Processing Manual, Chapter 20 - DME/POS, Parenteral and Enteral, Section 10.1 - Definitions)

DME is equipment which:

Can withstand repeated use;

Is primarily and customarily used to serve a medical purpose;

Generally is not useful to a person in the absence of an illness or injury; and

Is appropriate for use in the home.

All requirements of the definition must be met before an item can be considered to be durable medical equipment.

Section 110.1 also describes the underlying policies for determining whether an item 1) meets the definition of DME, and 2) may be covered.

Whether DME expenses are reimbursable (addressed in section 110):

Expenses incurred by a beneficiary for the rental or purchases of DME are reimbursable if the following three requirements are met:

1.　The equipment meets the definition of DME (section 110.1);

2.　The equipment is necessary and reasonable for the treatment of the patients illness or injury or to improve the functioning of his or her malformed body member (section 110.1); and

3.　The equipment is used in the patient’s home.

The subsection headings of 110 - Durable Medical Equipment are as follows:

110.1 - Definition of DME
110.2 - Repairs, Maintenance, Replacement, and Delivery
110.3 - Coverage of Supplies and Accessories
110.4 - Miscellaneous Issues Included in the Coverage of Equipment
110.5 - Incurred Expense Dates for Durable Medical Equipment
110.6 - Determining Months for Which Periodic Payments May Be Made for Equipment Used in an Institution
110.7 - No Payment for Purchased Equipment Delivered Outside the United States or Before Beneficiary’s Coverage Began

As described in Medicare Claims Processing Manual, Chapter 20, "Durable Medical Equipment, Surgical Dressings and Casts, Orthotics and Artificial Limbs, and Prosthetic Devices," Section 30 ("General Payment Rules"), Medicare recognizes the following payment classes of DME:

Inexpensive or other routinely purchased items
Items requiring frequent and substantial servicing
Certain customized items
Other prosthetic and orthotic devices
Capped rental items
Oxygen and oxygen equipment

Section 5101a of the Deficit Reduction Act (DRA) requires suppliers to transfer title of capped rental items after 13 continuous months of rental payments to beneficiaries [CMS Transmittal].

Previous rule allowed Medicare to pay rental for capped rental items for 15 months, and to still retain title.

DME MACs

· Jurisdiction A --Medicare NHIC

o Fee Schedules

· Jurisdiction B –AdminaStar Federal

· Jurisdiction C --CIGNA Government Services

· Jurisdiction D --Noridian

o Fee Schedules

CMS Jurisdiction Chart for alphanumeric HCPCS codes

SADMERC

Checklist for SADMERC HCPCS Coding Verification Reviews

Durable Medical Equipment and Supplies

Pricing, Data Analysis and Coding (PDAC) Contractor -- Noridian Administrative Services (as of August 18, 2008)

Provide data analysis support to the DME Program Safeguard Contractors (PSCs)
Guide manufacturers and suppliers on the proper use of the Healthcare Common Procedure Coding System (HCPCS) for Medicare billing purposes, through product reviews and decisions, the DMECS system and the HCPCS Helpline
Conduct national pricing functions for DMEPOS services
Assist CMS with DMEPOS fee schedules

PDACsections