2010 Carrier/A/B MAC Update SNF Consolidated Billing
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Coverage of Items in Nursing Facilities or Skilled Nursing Facilities
Certain items are covered for Medicare beneficiaries by the durable medical equipment Medicare administrative contractors (DME MACs) that reside in skilled nursing facilities (SNFs) (place of service [POS] code 31) or nursing facilities (NFs) (POS code 32). Determining which items can be covered depends upon the status of the Medicare Part A benefits of the beneficiary.
When a patient is in a facility and the Medicare Part A benefits have not been exhausted, customized prosthetic devices are the only items that can be separately billable to the DME MAC. A listing of which Healthcare Common Procedure Coding System (HCPCS) codes are separately payable is available on the Centers for Medicare & Medicaid Services (CMS) Web site at
Overview SNF Consolidated Billing.
When a patient is in a facility and the Medicare Part A benefits have been exhausted additional items can be covered under the DME MAC. The DME MAC
will not consider coverage of durable medical equipment (DME) such as, but not limited to:
- Wheelchairs
- Continuous passive motion devices
- Oxygen equipment, and
- Negative pressure wound therapy pumps
The DME MAC
will consider coverage on all other items such as, but not limited to:
- Surgical dressings
- Prosthetics
- Urological supplies
- Ostomy supplies
- Enteral and parenteral nutrition
- Orthotics
- Refractive lenses
- Therapeutic shoes for beneficiaries with diabetes
Note: Suppliers are encouraged to establish communication with the facility that the beneficiary is located in. The supplier will need to validate what type of care the beneficiary is receiving at the time services are rendered and if the beneficiary is in a Medicare Part A covered stay.
For the sole purpose of fitting or training the beneficiary on the proper use of a DME item, a supplier may deliver a medically necessary item of DME to a beneficiary who is in a Part A (covered or noncovered) facility stay. This may be done up to two days prior to the patient’s anticipated discharge to their home (POS code 12).
For the sole purpose of fitting or training the beneficiary on the proper use of a prosthetic or orthotic, a supplier may deliver the item to a beneficiary who is in a Part A covered facility stay. This may be done up to two days prior to the patient’s anticipated discharge to their home (POS code 12).
If delivery of the DME, prosthetic, or an orthotic was made but the discharge date has been changed, the supplier would need to document their files to reflect the correct date of discharge.
- If a denial of OA-109 (Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.) was received from the DME MAC, the supplier would need to resubmit the claim with the correct date of service. This requirement is located in the CMS Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 20, Section 110.3, “Pre-Discharge Delivery of DMEPOS for Fitting and Training.”
- If payment was received but the date of service does not show the correct date of discharge, the date of service can be changed by contacting the National Government Services telephone reopenings. Telephone reopenings will correct the date of service if there is not an overpayment involved. To request a telephone reopening, please contact the Telephone Reopening Unit (TRU) at 317-841-1307. Each call is limited to three claim issues. Please have the following information available before calling the TRU:
- The Medicare supplier number
- The Medicare claim control number (CCN) and reason for denia
- Beneficiary name and Medicare Health Insurance Claim number (HICN)
- Any additional information to support why they believe the decision was not correct.
If you are not sure whether the TRU can process your request, please contact the National Government Services Provider Contact Center (PCC) for assistance with determining which denials can be processed as a reopening. Please contact the PCC toll free at 866-590-6727 between the hours of 8:30 a.m. to 5:30 p.m. eastern time (ET).
List of Part B Items Covered in Nursing Home
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