Monday, December 31, 2001

SNFing out coverage for DME

Q. How can a supplier tell if the patient's residence is a skilled or intermediate care facility, or other classification where DME might or might not be covered?

A. This is one of the toughest areas for an HME supplier to receive a clear-cut answer. According to Medicare definition, a Skilled Nursing Facility is a "facility which primarily provides inpatient skilled nursing care and related services to patients who require medical nursing, or rehabilitative services but does not provide the level or care or treatment available in a hospital" (place of service code 31). An Intermediate Care Nursing Facility (place of service code 32) is defined as "a facility which primarily provides to resident skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals." These two levels of service are very easily identified and the rules are clear - no DME coverage in SNF or ICF facilities. And remember that many prosthetic, orthotic and supply items are covered in those situations as long as the patient is no longer in their Medicare Part A stay.

It is the other labels for other levels of service, such as the term "Assisted Living" that may pose a problem. Short of actually having the facility tell you what the patient's living quarters are classified as, here are a few things to look for:

1) Does the patient live in an apartment or cottage that is separate from the main facility? This would probably be safely considered the patient's home, place of service and DME should be covered by the DMERC;

2) If the patient resides in a room of the facility, could that bed, with another patient in it, be considered a Medicare or Medicaid bed? If so, DME needs should be met by that facility under its reimbursement methodology. If you choose to provide services to that patient, you should bill the facility directly.

3. How does the patient see the physician?

a. If they go out to the doctor's office, and live in an "Assisted Living" labeled facility, they may really be in a custodial care facility or they may be considered to be "at home" place of service 12. In this case DME needs may be covered by the DMERC.

b. If the doctor comes in to the facility to see the patient, odds are they are in a SNF or ICF level facility and DME probably won't be covered by the DMERC.

4. What does the State Board say about the licensure of the facility you are working with?

5. If you identify true custodial care facilities, where there is no medical component to the care, then DME needs would be covered by the DMERCs for place of service 33.

These are just a few items to think about when you are evaluating the facility you are working with. There are no clear-cut rules to help the DMEPOS supplier determine eligibility of a facility for this type of coverage. It is another one of many "gray" areas that suppliers must determine guidelines for themselves and all suppliers struggle with. See your Regional DMERC manual for a complete listing of all place of service codes and their definitions.

Nancy Burma is president of Alternative Billing Solutions. Reach her at 952-881-2416.