By Sandra Gauron, Appeals Coordinator
Pursuant to the Office of the Inspector General (OIG) report (OEI 06-16-00380), in which the OIG identified potential inappropriate payments to DME suppliers during non-covered SNF stays, CMS has tasked the SMRC to conduct post-payment reviews of DME claims in non-covered SNF stays. The dates of service for their reviews will be from DOS January 1, 2017-December 31, 2017. HCPCS under will be as follows:
- E0431: Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula, or mask, and tubing
- E0443: Portable oxygen contents, gaseous, 1 month’s supply = 1 unit
- E1390: Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate
- E1392: Portable Oxygen concentrator, rental
- K0738: Portable gaseous oxygen system, rental; home compressor use to fill portable oxygen cylinders; includes portable containers, regulator, flowmeter, humidifier, cannula, or mask, or tubing
The OIG found that 72 percent of the potential inappropriate DME claims were due to DME suppliers failing to correctly code the SNF as a facility. DME suppliers indicated on the claims a place of service as the beneficiary’s home and not a SNF, which bypassed an edit rejecting most DME provided at facilities. Additionally, they found that 98 percent of the inappropriate DME claims, SNFs did not submit a “no-payment bill”, indicating claims that document the dates of non-covered stays and do not result in payment.
The Additional Documentation Requests will indicate the reason for the review and request standard required documentation as well as documentation to support coverage for place of service 12, representing the beneficiary’s home or residence to include but not limited to:
- Demographic sheet, showing the beneficiary as a resident of the facility
- List of non-Medicare certified beds in the facility where items and supplies were delivered
- List of Medicare certified beds in the facility where items and supplies were delivered
- Room or bed assignment of the beneficiary during the dates of service
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