CWF Crossover Editing for DMEPOS Claims During an Inpatient Stay with example

I. General Information

A. Background:
In general, the DMEPOS benefit is meant only for items a beneficiary is using in his or her home. For a beneficiary in a Part A inpatient stay, an institutional provider (e.g., hospital) is not defined as a beneficiary’s home for DMEPOS, and so Medicare does not make separate payment for DMEPOS when a beneficiary is in the institution. The institution is expected to provide all medically necessary DMEPOS during a beneficiary’s covered Part A stay.

EXCEPTION: Medicare makes a separate payment for a full month for DMEPOS items, provided the beneficiary was in the home on the “from” date or anniversary date defined below.

For capped rental items of durable medical equipment (DME) where the DME supplier submits a monthly bill, the date of delivery (“from” date) on the first claim must be the “from” or anniversary date on all subsequent claims for the item. For example, if the first claim for a wheelchair is dated September 15, all subsequent bills must be dated for the 15th of the following months (October 15, November 15, etc.).


B. Policy:

If a beneficiary using DMEPOS is at home on the “from” date or anniversary date, Medicare pays for the DMEPOS for the entire month, even if the “from” date is the date of discharge from the institutional provider.

If a beneficiary using DMEPOS is in a covered Part A stay for a full month, Medicare does not make payment for the DMEPOS for that month.

For capped rental items, if the covered Part A stay overlaps the anniversary date (“from” date on the claim), and the beneficiary is not in the covered Part A stay for the entire month, the date of discharge becomes the new anniversary date (“from” date on the claim) for subsequent claims. In this situation, the supplier must submit a new claim with the date of discharge as the new anniversary date upon the beneficiary’s release from the institution. Suppliers should annotate the claims, to indicate that the patient was in an institution, resulting in the need to establish a new anniversary date.

The CWF:

• rejects a DME MAC claim that contain DMEPOS HCPCS codes when the DME MAC claim has a date of service that falls within the inpatient stay;

• considers an inpatient stay to include all days prior to the date of discharge;

• processes a DME MAC claim that contain DMEPOS HCPCS codes when the DME MAC claim has the same “from” date equal to the date of inpatient discharge;

• validates for a crossover service on a DME MAC claim for an inpatient beneficiary based on the “from” date only of the DME MAC claim;

• identifies a DME MAC claim for maintenance and servicing by the “MS” modifier;

• allows payment for a DME MAC claim for maintenance and servicing of capped rental items when a claim contains the “MS” modifier.


The CWF approves to pay maintenance and servicing claims regardless of whether the beneficiary is in an institutional setting or in the home environment.

The changes in the general policy apply to all items of DMEPOS paid by the DME MACs, however, changes in anniversary date billing apply only to capped rental DME.

In cases where the anniversary date falls at the end of the month (for example January 31) and a subsequent month does not have a day with the same date (for example, February), the DME MAC uses the final date in the calendar month (for example, February 28).

EXAMPLE 1:

A beneficiary rents a wheelchair beginning on January 1. The DME MAC determines that the wheelchair is medically necessary and that the beneficiary meets all coverage criteria, and so begins to make payment on the wheelchair. The beneficiary enters a covered a hospital on February 15 and is discharged on April 5.

In this example, Medicare pays for the entire month of February, because the patient was in the home for part of the month. However, the DME MAC denies the claim for March, because the patient was in a covered hospital stay for the entire month.

Because the anniversary date (“from” date) of the monthly bill was April 1, and the patient was still in the covered hospital stay on that date, the DME supplier must not submit another claim until April 5 (the date of discharge). April 5 becomes the new anniversary date (“from” date) for billing purposes, so the supplier would now bill on the 5th of the month rather than the 1st of the month for the remainder of the capped rental period. The supplier should annotate the claim to indicate that the patient was in a hospital on the first claim with the new anniversary date.


EXAMPLE 2:

A beneficiary receives oxygen on January 1. On February 28, the patient enters a hospital and is discharged on March 15.
In this example, the DME MAC denies a claim dated March 1. The supplier submits a new claim dated March 15, which would then become the anniversary date for billing purposes. The supplier should annotate the claim to indicate that the patient was in a hospital on the first claim with the new anniversary date.

EXAMPLE 3:

A beneficiary rents a hospital bed beginning on January 1. On March 15, the patient enters a hospital and is discharged on March 25.
In this example, the DME MAC pays for the entire month of March.

EXAMPLE 4:

A beneficiary rents a wheelchair beginning December 15. On January 1, the patient enters a hospital and is discharged on January 31.

In this example, the DME MAC denies the claim dated January 15. The supplier submits a new claim dated January 31, which becomes the anniversary date for billing purposes. The supplier should annotate the claim to indicate that the patient was in a hospital on the first claim with the new anniversary date. The February claim would be dated February 28 because there is no 31st day in February.