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MIPS DRIVES SUCCESS BY PROMOTING FALL RISK ASSESSMENT, FITTING SHOES, ORTHOSES & AFOS

Failure to submit Medicare MIPS quality measures will cost physicians tens of thousands of dollars. In 2018, podiatrists have to submit quality measures all year and not for just a 3-month window, like in 2017. Also, the penalty for not submitting increased to 5% of Medicare payments. However, podiatrists should appreciate that performing MIPS measures may also allow billing for office visits and will increase awareness of when balance AFOs, payable by Medicare, should be prescribed.

DON’T BE HIT WITH MIPS PENALTIES: DOWNLOAD THE LATEST MIPS FALL RISK ASSESSMENT TOOL HERE

MIPS quality measures 154, falls risk assessment and 155, falls, plan of care, address falls being the leading cause of injuries for older adults. One in four Americans aged 65 and over falls each year. By identifying people with gait instability, podiatrists can reduce this risk and make fall prevention a valuable part of their practice.

Physicians should annually, ask every patient, 65 and over, whether they have fallen in the past year. If so, they should follow-up by asking how many times and if the patient suffered an injury. Patients who have fallen two or more times or once with injury are defined to be at high risk.

These patients should be evaluated using a fall risk assessment form available from SafeStep.
Gait, strength and balance are assessed by having patients perform a “Timed Up and Go Test”. Patients stand, walk 10 feet, turn around and sit down. If TUG takes more than 12 seconds, there’s a good chance such conditions as: muscle weakness, difficulty walking or unsteadiness on feet are present.

MIPS 154 also requires assessing another contributing factor to falling including:
• a review of medications, or
• asking if the patient has had an eye exam in the past year, or
• reviewing other possibly contributing medical conditions, or
• determining the presence of postural hypotension.

Patients should be provided with a Plan of Care that includes balance, strength and gait training instructions, advice about vitamin D and information about home fall hazards. To make it easy, when using the assessment form available from SafeStep, simply tear off and give the patient a sheet that’s part of it.

When patients have NOT fallen two or more times or once with injury, submit MIPS quality measure 154 using CPT code 1101F.

If patients at high risk for falls are evaluated and provided a plan of care, consider billing E&M code 99213. Also submit codes 3288F and 1100F for MIPS 154 and 0518F for MIPS 155.
When there is fall risk, based on gait assessment, consider prescriptions for balance footwear, foot orthotics and possibly balance AFOs.

SafeStep has available, for free, copies of a Fall Risk Assessment form that assists in satisfying the MIPS fall prevention requirements. Medicare compliance documentation for AFOs can be best assured by using SafeStep’s WorryFree DME program.

Medicare DME Reimbursement Increases in 2018

Good news!
On January 1, 2018, Medicare increased the amount it pays for diabetic shoes, Moore Balance Brace and Arizona custom AFOs.

While the amounts paid may vary slightly by state, the National Fee Schedule is as follows:
Depth Shoes (A5500): pair $143.12
Prefabricated, Heat Molded Inserts (A5512): pair $58.38
Custom Molded Inserts (A5513): pair $87.12
Depth Shoes w/3 pr. Prefab, Heat Molded Inserts: $318.26
Depth Shoes w/3 pr. Custom Molded Inserts: $404.48
Custom Molded Shoes w/offset heels and rocker bottoms: $570.38
Arizona AFO, Standard (L1940, L2330, L2820): each – Ceiling $1178.61 Floor $883.96
Moore Balance Brace (L1940, L2330, L2820): pair – Ceiling $2357.22 Floor $1767.92

For a complete listing of updated DME allowables, including prefabricated and custom ankle-foot orthoses, visit:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule-Items/DME18-A.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending

MIPS DRIVES SUCCESS BY PROMOTING CDFE AND SHOE FITTING IN 2018

Failure to submit Medicare MIPS quality measures will cost physicians tens of thousands of dollars. In 2018, podiatrists have to submit qualify measures all year and not for just a 3-month window, like in 2017. Also, the penalty for not submitting increases to 5% of Medicare payments. However, podiatrists should appreciate that performing MIPS measures may also allow billing for office visits and will increase awareness of when shoes and inserts, payable by Medicare, should be prescribed.

MIPS quality measures 126 and 127, diabetic foot exam including evaluation of footwear, address the association of neuropathy with diabetic foot ulceration. Properly fit shoes have been demonstrated to significantly reduce the likelihood of foot ulceration in patients with diabetes. By identifying people who qualify for shoes paid for by Medicare, podiatrists can make shoe fitting a valuable part of their practice.
Podiatrists should annually perform an ulcerative risk assessment on every patient with diabetes. A CDFE should include testing for loss of protective threshold using a 10-gram monofilament plus at least one of the following neurological exams including feeling vibration using a tuning fork, pinprick sensation, or ankle reflexes. Testing should also look for vascular, dermatological and structural findings. The foot should be sized using a standard measuring device, and the patient counseled on appropriate footwear based on risk categorization.

Patients with Medicare and diabetes who are identified to be at increased risk for ulceration should be fit with shoes and inserts. Shoe fitting will be most successful when patients are recommended models based on the consideration of what’s referred to as the 4 S’s of shoe fitting: Size, Shape, Stability & Style.

When patients with diabetes are given a comprehensive diabetic foot exam and provided a plan of care, which may include prescribing shoes, consider billing E&M code 99213. Also, submit codes G8404 for MIPS 126 and G8410 for MIPS 127.

SafeStep has available, for free, copies of a CDFE form that assists in satisfying the MIPS diabetic foot examination requirements. Medicare compliance documentation for diabetic shoe-fitting can be best assured by using SafeStep’s WorryFree DME program.

To access SafeSTep training and webinars, visit:

DME Training

Free Webinar Instructionals

New Billing Codes for Plantar Fascia Night Splints, Pneumatic and Non-pneumatic Walking Casts

Medicare now differentiates between off-the-shelf and custom fitted type prefabricated AFOs including pneumatic and non-pneumatic walkers and plantar fascia night splints.

Traditionally used codes reflect the custom fitted version and the allowable amounts for both are currently the same.  For devices traditionally billed using L4360, L4386 and L4396, new codes reflecting the off-the-shelf definition most likely apply.

Click below to read entire article:

NEW BILLING CODES FOR PLANTAR FASCIA NIGHT SPLINTS, 150127

Increased Medicare DME Reimbursement for 2015

Good news!! On January 1, 2015, the Medicare fee schedule for diabetic shoes, Moore Balance Brace and Arizona custom AFOs increased. While the amount reimbursed by each DME MAC may vary slightly, the National Fee Schedule allowables are as follows:

Depth Shoes (A5500) $141.14
Prefabricated, Heat Molded Inserts (A5512) $57.58
Custom Molded Inserts (A5513) $85.92

Depth Shoes w/ 3 pr. Prefab, Heat Molded Inserts $313.88
Depth Shoes w/ 3 pr. Custom Molded Inserts $398.90
Custom Molded Shoes w/ Custom Molded Inserts $586.42

Arizona AFO, Standard (L1940, L2330, L2820) $1162.23
Moore Balance Brace (L1940, L2330, L2820) $1162.23

For a complete listing of updated DME prices, including prefabricated and custom ankle foot orthoses, go to:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html.

What is the Difference Between the PDAC and the DME MACs?

Function of the PDAC

One function of the Pricing Data Analysis and Coding Contractor is to determine an appropriate Healthcare Common Procedure Coding System (HCPCS) code to use when submitting claims to Medicare. A HCPCS code identifies the durable medical equipment, prosthetics, orthotics, and/or supplies (DMEPOS) being billed.

PDAC Responsibilities

  • Operate a Contact Center to provide coding advice and guidance
  • Maintain DMECS, a web-based interactive tool that provides HCPCS coding assistance and national fee schedule information
  • Respond to written inquiries requesting HCPCS coding assistance
  • Coordinate and participate in requests for HCPCS Coding Verification Reviews
  • Maintain a NDC/HCPCS crosswalk applicable for DME MAC billing

Who is Calling the PDAC?

  • Suppliers
  • Manufacturers
  • Distributors
  • OIG (Office of Inspector General)
  • CMS (Centers for Medicare & Medicaid Services)
  • Consultants
  • Attorneys
  • Doctor Offices
  • Pharmacies
  • Billing Services
  • Other Insurance Carriers
  • DME MACS
  • Medicaid
  • Attorney General Office

PDAC Can:

  • Provide HCPCS coding determinations
  • Provide allowables for items that are on the DMEPOS Fee Schedule

PDAC Cannot:

  • Provide codes for items that are not billable to the DME MACS
  • Answer coverage or policy questions including the use of modifiers
  • Address claim inquiries
  • Provide beneficiary eligibility
  • Assist with questions concerning claim form(s)
  • Address required documentation for claims submission
  • Provide allowables for items that are not on the DMEPOS Fee Schedule
  • Provide publications such as the Supplier Manual, bulletins or DMEPOS Fee Schedules
  • Address CMN or DIF Information
  • Assist with Type of Service or Place of Service codes
  • Provide Diagnosis Codes

Type of Calls Referred to the DME MAC:

  • Coverage and Utilization Questions
  • Eligibility
  • Claim Inquiries
  • Claim Form(s)
  • Required Documentation
  • Allowables for items priced by reasonable charge and individually considered items
  • Publications: Supplier Manual, bulletins and Fee Schedules
  • CMN/DIF Information
  • Type of Service and Place of Service Codes

Results of Widespread Prepayment Probe Review of Ankle-Foot/Knee-Ankle-Foot Orthosis (HCPCS L4360, L1970 and L1960)

Review Results

Jurisdiction D DME MAC Medical Review Department completed a widespread prepayment probe review of HCPCS codes L4360, L1970 and L1960. This review was initiated based on CERT analysis.

The L4360 review involved 101 claims of which 97 were denied. This resulted in an overall error rate of 97%.

The L1970 review involved 100 claims of which 80 were denied. This resulted in an overall error rate of 79%.

The L1960 review involved 100 claims of which 69 were denied. This resulted in an overall error rate of 68%.

Primary documentation errors that resulted in denial of claims

• 21% of L4360 claims received a denial as basic coverage criteria not met.

• 21% of L1970 claims received a denial as basic coverage criteria not met.

• 30% of L1960 claims received a denial as basic coverage criteria not met.

Medical records are insufficient to support basic coverage criteria.

BASIC COVERAGE CRITERIA: Ankle-foot orthoses are covered for ambulatory beneficiaries with weakness or deformity of the foot and ankle, who require stabilization for medical reasons, and have the potential to benefit functionally.

•  21% of L1970 claims received a denial as criteria 1,2,3,4 or 5 not met.

•  32% of L1960 claims received a denial as criteria 1,2,3,4 or 5 not met.

1 of the 5 following criteria were not met:

•  The beneficiary could not be fit with a prefabricated AFO; or

•  The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months); or,

•  There is a need to control the knee, ankle or foot in more than one plane; or

•  The beneficiary has a documented neurological, circulatory or orthopedic status that requires custom fabricating over a model to prevent tissue injury; or,

• The beneficiary has a healing fracture which lacks normal anatomic integrity or anthropometric proportions.

20% of L4360 claims received a denial as no proof of delivery submitted.

7% of L1960 claims received a denial as no proof of delivery submitted.

No proof of delivery submitted.

Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. For medical review purposes, POD serves to assist in determining correct coding and billing information for claims submitted for Medicare reimbursement. Regardless of the method of delivery, the contractor must be able to determine from delivery documentation that the supplier properly coded the item(s) submitted for Medicare reimbursement and that the item(s) are intended for, and received by, a specific Medicare beneficiary.

• 42% of L4360 claims received a denial as no written or verbal order received.

• 7% of L1970 claims received a denial as no written or verbal order received.

• 5% of L1960 claims received a denial as no written or verbal order received.

No written or verbal order received.

All items billed to Medicare require a prescription. An order for each new or full replacement item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request.

Equipment and supplies may be delivered upon receipt of a dispensing order except for those items that require a written order prior to delivery. A dispensing order may be verbal or written. The supplier must keep a record of the dispensing order on file. It must contain:

• Description of the item

• Beneficiary’s name

• Prescribing Physician’s name

• Date of the order and the start date, if the start date is different from the date of the order

• Physician signature (if a written order) or supplier signature (if verbal order)

 

For items that are provided based on a dispensing order, the supplier must obtain a detailed written order before submitting a claim. Detailed written order (DWO) is required before billing. Someone other than the ordering physician may produce the DWO. However, the ordering physician must review the content and sign and date the document. It must contain:

• Beneficiary’s name

• Physician’s name

• Date of the order and start date, if start date different than date of order

• Detailed description of the item(s)

• Physician signature and signature date

Going Forward

Based on high error rate, Noridian Administration Services will close this probe review and begin a widespread targeted review on HCPCS codes L4360, L1970 and L1960.

To review entire article please click here

Implications of the New Medicare AFO Reimbursement Policy and Suggestions How to Appropriately Bill Prefabricated and Custom Fabricated Devices

New Medicare reimbursement policy requires prefabricated and custom AFOs coded as L1900 and between L1910 and L1990 to extend to 4 cm below the fibular head. Established policy also requires L1906 devices to have effective PDAC verification.

http://www.cms.gov/medicare-coverage-database/details/article-details…

Some commonly used AFOs are unaffected by this change, some AFOs should be coded differently, some AFOs are being developed to comply with the new changes and some AFOs no longer qualify for reimbursement.

The following is a review of commonly used prefabricated and custom AFOs with suggestions how to appropriately code in light of these recent changes.

L1902, “AFO ankle gauntlet, prefabricated”
Unaffected by the new policy.
Not required to have PDAC verification nor need extend as high as to near the fibular head.
The 2013 fee schedule ranges, depending on the state, from $69.69 to $92.92.
Examples, recommended by the manufacturers and by SafeStep to be billed as such include:

Ossur Gameday, Exoform
Aircast A60
Bledsoe Axiom
Darco Web, Sport, Pro
Medspec ASO
SafeStep DME Multiligamentous Sport
Swede-O Ankle-Lok, Step Smart


L1906, “AFO multiligamentous ankle, prefabricated”

Since 7/1/2012, have been required to have, active PDAC verification, “a hinged ankle and a rigid stirrup and foot plate which provides functional tracking of the ankle with hind-foot and mid-foot stability during ambulation.”.
The 2013 fee schedule ranges, depending on the state, from $104.99 to $241.94.
Examples of such devices with active PDAC verification include:

Darco Body Armor Vario
Medspec EVO Hinge
Swede-O Arch Lok, Atom, Dorsi-Assist
United Surgical Trailblazer Hinged Ankle

DPMs are advised to consult the PDAC website, www.dmepdac.com to ensure that PDAC verification is present and active. There are products that could has design features to qualify as L1906 but have not had PDAC revalidation, as required, subsequent to last year’s Policy change. Products which have not received coding verification from the PDAC must be billed using code A9270, “non-covered item or service”. The above list is as of 1/13/2013 and is subject to change. For a complete list of L1906 devices with effective L1906 verification click:
https://www.dmepdac.com/dmecsapp/do/product search


L1907, “AFO supramalleolar, with straps”

Custom fabricated and not required to extend as high as required by the Policy Article.
PDAC verification not required.
The 2013 fee schedule for such devices ranges, depending on the state, from $512.77 to $564.06.


L1930, “AFO plastic or other material, prefabricated”

Required to extend as high as specified by the Policy Article.
PDAC verification not required.
The 2013 fee schedule for such devices ranges, depending on the state, from $170.94 to $326.70.
Examples recommended by the manufacturers and by SafeStep to be billed as such include:

FLA Orthopedics Foot Drop Splint
Ossur AFO Light


L1951, “AFO, spiral plastic or other material, prefabricated”

Required to extend as high as specified by the Policy Article.
PDAC verification not required.
The 2013 fee schedule for such devices ranges, depending on the state, from $765.34 to $841.84.
Examples recommended by the manufacturers and by SafeStep to be billed as such include:

Eurointernational             Perosupport (formerly Peromax)


L1971, “AFO with ankle joint, prefabricated”

Required to extend as high as near to the fibular head.  If not, no longer qualify as Medicare reimbursable. Some, like the Swede-O SureStep, though still listed on the PDAC website as L1971, because they do not meet the height requirement, should no longer be billed as such. Some like the Ossur Rebound and the Donjoy Velocity, while lacking PDAC verification, had been recommended by the manufacturer and by SafeStep, prior to January 1, 2013, to be billed as L1971. They should no longer be billed as such. Manufacturers are submitting these devices to PDAC to determine their qualification for L1906 verification. If so, and only then, would they qualify for Medicare reimbursement as such.


L2340, “pre-tibial shell, molded to patient model”

According to the January 2013 Policy Article, “Must extend to between the tibial tuberosity and to within 3 inches of the medial malleolus”.
As a custom item, it “involves substantial work such as cutting, bending, molding, sewing, etc. It involves more than trimming, bending, or making other modifications to a substantially prefabricated item”.
PDAC verification not required.
The 2013 fee schedule ranges, depending on the state, ranges from $390.10 to $582.88


L4350, “ankle control orthosis, stirrup style, rigid”

Not required to extend as high as the knee.
PDAC verification is not required. Unaffected by the recent Policy Article.
The 2013 fee schedule ranges, depending on the state, from $78.04 to $147.33.
Examples recommended by the manufacturers and by SafeStep to be billed as such include:

Ossur Formfit, Airform Universal
Aircast Airlift PTTD, Airsport, Air Stirrup
SafeStep DME Air Stirrup, Foam Stirrup
Swede-O Versi-Splint


L4361, “AFO walking boot type, varus / valgus correction (CROW)”

Not required to extend as high as the knee.
PDAC verification is not required. Defined by LCD revision of 1/1/2011.
The 2013 fee schedule ranges, depending on the state, from $1400.89 to $1931.59.


L4386, “Walking boot, non-pneumatic”

Not required to extend as high as the knee.
PDAC verification is not required.
Unaffected by the recent Policy Article.
The 2013 fee schedule for such devices ranges, depending on the state, from $144.49 to $158.95.


L4396, “static or dynamic AFO including soft interface, adjustable for fit, for positioning, minimal ambulation, prefabricated”

(Plantar fascia night splints)
Must as of 1/1/10 have adjustability. Many dorsal night splints commonly billed using this code lack “adjustably for fit” and so do not qualify for Medicare reimbursement. This item is an exception in that while others AFOs need be for ambulation, L4396 needs not when used for treatment of plantar fasciitis (728.71) or as part of a treatment plan for plantar flexion contracture of 10 degrees or greater (718.47).
The 2013 fee schedule ranges, depending on the state, from $150.37 to $183.51.


Arizona-type AFO

PDAC verification and an Advisory Article remain in place for Arizona AFO type custom gauntlets and as such, the Medicare DME MAC AFO redefinition for billing such devices DOES NOT require them to reach the new height requirement. According to PDAC:

If you are supplying an Arizona Style Ankle Gauntlet, then the PDAC coding article applies and the device can be delivered as an Arizona Style Gauntlet. The confusion takes place in the nomenclature and descriptor of the ankle gauntlets. These ankle gauntlets are listed in many coding materials as: AFO Ankle Gauntlet, giving way to many thinking these are AFO’s when they are truly ankle gauntlets. The classification and listing language are merely for reference and not indicative of their true functional purpose: the ankle joint complex.

The manufactures have read into the definition and not fully understood that an AFO is well defined and should be followed when supplying one of these orthotic devices. The PDAC advisory article: Ankle-Foot Orthoses – Arizona-Type – Correct coding – Revised<https://www.dmepdac.com/resources/articles/2011/11_15_11.html>, applies when delivering an Arizona type AFO.

Should you need any further assistance please call the PDAC Contact Center at 877-735-1326. Hours of operation are Monday through Friday, 8:30 a.m. to 4 p.m. CT.

PDAC
www.dmepdac.com<http://www.dmepdac.com/> 

According to the PDAC Advisory Article, Arizona Short and Arizona Tall, or similar custom fabricated braces (including the Moore Balance Brace), only the following codes should be used:
L1940 Ankle foot orthosis, plastic or other material, custom fabricated
L2330 Addition to lower extremity, lacer or Velcro closure, molded to patient model, for custom fabricated orthosis only
L2820 Addition to lower extremity orthosis, soft interface for molded plastic below knee section
The 2013 fee schedule ranges, depending on the state, from $850.37 to $1389.58.

For the Arizona Extended and the Arizona Unweighting or similar custom fabricated braces, only the following codes should be used:
L1960 Ankle foot orthosis, posterior solid ankle, plastic, custom-fabricated
L2330 Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only
L2820 Addition to lower extremity orthosis, soft interface for molded plastic below knee section
The 2013 fee schedule ranges, depending on the state, from $902.52 to $1484.25.


Thermoplastic hinged articulated AFO

Devices that meet the description as L1970, “AFO, plastic with ankle joint, custom fabricated” are as of 1/1/13, according to the new AFO Policy Article, required extend to within 4 cm of the fibular head. When they include a soft interface, code L2820 can also be billed.
AFO manufacturers, including Arizona AFO have old and are developing new, models that qualify for reimbursement.  Compliance requires that higher devices be casted for up to the knee.

Examples of these devices will be shown at the SAM and NY Clinical Conferences.
The 2013 fee schedule for such devices ranges, depending on the state, from $621.03 to $929.37.
APMA, the American Orthotics and Prosthetics Association and others continue in their efforts lower the new AFO height requirement to a scientifically justified level as well as to allow the Arizona AFO-type Policy Article provide qualification for reimbursement.

The final and sole responsibility for correct coding, within established laws, rules and standards of practice, rests upon the party submitting the claim.

Your comments are welcome and appreciated. Updates relating to this and other coding, billing and compliance issues will be posted on the SafeStep blog, www.safestepblog.net.

Josh White, DPM, CPed

Arizona AFO Coding Guidelines

There has been some confusion and misunderstanding lately regarding Medicare requirements for the proximal height of custom molded AFOs. We want to assure you that when billing for an Arizona AFO that the Medicare Pricing, Data Analysis and Coding (PDAC) Advisory Article, dated 11/22/11 https://www.dmepdac.com/resources/articles/2011/11_15_11.html, is still in effect and the coding stated should continue to be used for 2013.

The management of Arizona AFO, Inc. has personally spoken with the coding expert at the PDAC. He stated that this advisory article is in effect and that when billing an Arizona AFO, providers should continue to follow those guidelines.  He emphasized that if an AFO does not have PDAC assigned coding then it must meet the new height definition.

PDAC assigned coding is important and that is why Arizona AFO went through the process of having it’s products evaluated so that you may code with confidence.

Here is link to all AZ AFO products that have PDAC assigned codes. Enter “Arizona AFO” as the manufacturer: https://www.dmepdac.com/dmecsapp/do/productsearch.

Thank you for your business and for your continued trust in our company and our products! We look forward to serving you and your patients with quality service and products for many years to come.

Best regards,

Josh White, DPM, CPed
President / Founder
SafeStep, LLC

What to Do if a Patient Doesn’t Pick Up Their DME Product?

Question:

If a DME product was fabricated and paid by the carrier, but the patient does not come to pick it up despite proper scheduling, what is the responsibility of the podiatrist?

Answer:

Medicare Benefit Policy Manual
Chapter 15 – Covered Medical and Other Health Services

Publication 100-02, Chapter 15, Section 20.3

20.3 – Artificial Limbs, Braces, and Other Custom Made Items Ordered But Not Furnished
(Rev. 1, 10-01-03)
B3-2005.3

A. Date of Incurred Expense
If a custom-made item was ordered but not furnished to a beneficiary because the individual died or because the order was canceled by the beneficiary or because the beneficiary’s condition changed and the item was no longer reasonable and necessary or appropriate, payment can be made based on the supplier’s expenses. (See subsection B for determination of the allowed amount.) In such cases, the expense is considered incurred on the date the beneficiary died or the date the supplier learned of the cancellation or that the item was no longer reasonable and necessary or appropriate for the beneficiary’s condition. If the beneficiary died or the beneficiary’s condition changed and the item was no longer reasonable and necessary or appropriate, payment can be made on either an assigned or unassigned claim. If the beneficiary, for any other reason, canceled the order, payment can be made to the supplier only.

B. Determination of Allowed Amount
The allowed amount is based on the services furnished and materials used, up to the date the supplier learned of the beneficiary’s death or of the cancellation of the order or that the item was no longer reasonable and necessary or appropriate. The Durable Medical Equipment Regional Carrier (DMERC), carrier or intermediary, as appropriate, determines the services performed and the allowable amount appropriate in the particular situation. It takes into account any salvage value of the device to the supplier.

Where a supplier breaches an agreement to make a prosthesis, brace, or other custom-made device for a Medicare beneficiary, e.g., an unexcused failure to provide the article within the time specified in the contract, payment may not be made for any work or material expended on the item. Whether a particular supplier has lived up to its agreement, of course, depends on the facts in the individual case.

There are slight variations in the procedure of each DME carrier and the provider has to call and find out and follow those, but for the most part they are similar to what is outlined below.

According to National Government Services, one of four Medicare DME MACs:

1) Submit a claim with the FULL billing amount you usually bill.
a. Date of Service should be Date of Refusal or Date of Death
2) Include in the narrative section a brief explanation of the situation. Mention that the item ‘has no salvage value and is a complete loss’.
3) After receipt of claim, they may ask for more information such as a receipt of the purchase of the item, explanation of your other related costs such as staff time, your own time, etc. It is their discretion depending on many factors such as How often you have claims such as this, the total amount involved, and other DME history of patient and provider.
4) Based on all this, the carrier will pay whatever they feel is appropriate, even up to the full amount billed or….nothing at all!
5) This decision can be appealed up to the various levels following usual procedures