CMS has had a longstanding policy to deny claims for DME while patients are in a SNF. But oftentimes, DME rentals get billed before the SNF data is in place to deny the claim and this causes routine erroneous payments. Quite often the MACs would initiate special project recoupments for DME claims that erroneously paid while the patient was in a SNF. However, recently CMS created Common Working File (CWF) edits to more consistently identify and recover these erroneous payments. An education article announcing the change was issued via CR 8172, but that directive spoke only to O&P. A new CR 8844 completes the cycle by addressing DME consideration along with a carve out to permit the “from” DOS to equal a date of discharge (as long as there is no evidence the patient was admitted to a difference inpatient setting on the same day). This edit will be effective on April 1, 2015, and will “trigger recoupment for DME items while the beneficiary was in a hospital inpatient stay.”
The logic has a carve out for status codes that indicate the patient is supposed to be transferred to a facility, but there is no evidence that they have been transferred by means of a billable claim from the SNF. This exception applies to patient status code of 03 (Discharged/Transferred to a Skilled Nursing Facility [SNF] with Medicare Certification in Anticipation of Skilled Care) and 83(Discharged/Transferred to a Skilled Nursing Facility [SNF] with Medicare Certification with a Planned Acute Care Hospital Inpatient Readmission) where the Skilled Nursing Facility claim is not on file. The edit will also not apply if the “from” date on the DME claim is the same as the discharge date and the patient status code indicates they are discharged to a location where DME is payable:
- 01 – discharged to home or self-care,
- 06 – discharged/transferred to home under care of an organized home health service organization in anticipation of covered skilled care,
- 50 – discharged/transferred to Hospice- home,
- 81 – discharged to home or self-care with a planned acute care hospital inpatient readmission, or
- 86 – discharged/transferred to home under care of an organized home health service organization with a planned acute care hospital inpatient readmission.
- Remark code PR96 - Non-covered Charge(s)
- Remark code M18 – Certain Services may be approved for home use. Neither a hospital nor a Skilled Nursing Facility (SNF) is considered to be a patient’s home.
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