To: Centers for Medicare Medicaid Services

Date: 12/29/2012

To: Centers for Medicare Medicaid Services

From: IV PEN Team Region D DAC

Regarding: Skilled nursing facility residents that move from a Part A status, to a Part B status,but remain in the SNF.

Part B suppliers that provide consumable products such as enteral nutrition, ostomy, trach, surgical dressings and urological supplies to beneficiaries residing in a SNF are receiving claim denials due to the overlap of shipping days while the beneficiary is on a Part A stay.

Prospective billing requires that the beginning date of service on a claim be either the date of shipping or date of delivery. In order for the supplies to be available for use on the first day the beneficiary's payer status changes from Part A to Part B, they must be delivered prior to the first Part B date causing “inpatient” claim denials and adding to the burden of appeals.

The only current exception noted for the date of service on the claim is for residents discharging to their home from an inpatient stay which allows the supplier to deliver products two days prior to discharge and use the discharge date as the date of service on the claim. Per PIM:

4.26.2 – Exceptions

(Rev. 83, Issued: 08-27-04, Effective: 09-27-04, Implementation: 09-27-04)

Exceptions to the preceding statements concerning the date(s) of service on the claim occur when the items are provided in anticipation of discharge from a hospital or nursing facility. A supplier may deliver a DMEPOS item to a patient in a hospital or nursing facility for the purpose of fitting or training the patient in the proper use of the item. This may be done up to 2 days prior to the patient’s anticipated discharge to their home. The supplier shall bill the date of service on the claim as the date of discharge and shall use the Place of Service (POS) as 12 (Patient’s Home). The item must be for subsequent use in the patient’s home. No billing may be made for the item on those days the patient was receiving training or fitting in the hospital or nursing facility.

A supplier may not bill for drugs or other DMEPOS items used by the patient prior to the patient’s discharge from the hospital or a Medicare Part A nursing facility stay. Billing the DMERC for surgical dressings, urological supplies, or ostomy supplies that are provided in the hospital or during a Medicare Part A nursing facility stay is not allowed. These items are payable to the facility under Part A of Medicare. This prohibition applies even if the item is worn home by the patient from the hospital or nursing facility. Any attempt by the supplier and/or facility to substitute an item that is payable to the supplier for an item that, under statute, should be provided by the facility, may be considered to be fraudulent. These statements apply to durable medical equipment delivered to a patient in hospitals, skilled nursing facilities (Place of Service = 31), or nursing facilities providing skilled services (Place of Service = 32).

We would like to ask CMS to consider allowing a similar exception for inclusion of situations wherein the beneficiary transitions from Part A to Part B while remaining in the SNF. This additional exception would solve this issue, as it would then allow the date of service on the claim to be the first Part B stay date while allowing the delivery to take place up to 2 days prior to discharge from Part A benefit into the Part B DMEPOS benefit..

The MACs will need to make sure that they do not consider Part A “no pay” dates as actual paid Part A days where Medicare is paying room and board, otherwise they will continue to improperly deny for inpatient status.

Improper claim denials for overlapping inpatient dates would be eliminated altogether if suppliers were allowed to use the intended usage dates as the dates of service on the claim.

Thank You,

Region D DAC

IV PEN A TEAM