Index
of General Facts:
Durable
Medical Equipment (DME) defined
Medicare makes payment for the
rental or sale of certain
Durable Medical Equipment (DME)
defined as follows:
- It can withstand repeated
use.
- It is primarily used to serve
a medical purpose.
- It is appropriate for home
use.
- It is used in the patient's
home.
- It would not be used in the
absence of illness or injury.
Medicare pays for DME used only
in the patient's own home. A patient's
home could also be a relative's
home or foster care. Medicare pays
for items that are medically adequate,
not for deluxe or luxury products.
Medicare
payment requires a physician's prescription
Any DME item submitted for Medicare
payment requires a physician's prescription,
also known as a Certificate of Medical
Necessity (CMN). The CMN is initiated
by the supplier and signed by the
physician. The maximum length of
time equipment can be prescribed
is 12 months, at which time the
supplier must request another CMN
from the doctor. Doctors cannot
charge for providing the patient
or DME supplier with a CMN for medical
equipment.
Specific
Coverage Requirements for DME
Most pieces of DME have specific
coverage requirements. For example,
a bedside commode is covered only
if the patient is bed-or room-confined.
A wheelchair is covered only if
the patient is unable to walk without
assistance. Medicare coverage of
certain DME items will not be covered
simultaneously. For example, a wheelchair
and a walker will not be covered
at the same time. Click
Here for specific product coverage
information.
Health-E-Quip
retails three categories of DME reimbursed
by Medicare
- Inexpensive and Routinely
Purchased Equipment -
Inexpensive items are those costing
less than $150. It is to the patients
advantage to purchase these items.
Examples: Walkers, canes, crutches,
and bedside commodes.
- Oxygen and Oxygen Equipment
- Oxygen equipment can be rented
as long as the need continues.
Purchase of oxygen equipment is
not reimbursable by Medicare.
Medicare reimburses a fixed fee,
regardless of the amount of oxygen
used and regardless of the type
of oxygen equipment provided (such
as concentrator, cylinder or liquid
oxygen system).
Medicare reimbursement for oxygen
patients requires a blood gas
analysis report, certifying a
PO2 level of 55 mm Hg and/or SaO2
of 88% or below when at rest and
breathing room air. Re-testing
may be required periodically to
establish continued medical necessity.
- Capped Rental Items
- These include such items as
semi-electric hospital beds, manual
wheelchairs, CPAP, and nebulizers.
Monthly rental is reimbursed as
long as medical necessity continues,
for up to 15 months.
During the tenth rental month,
the supplier (Health-E-Quip) is
required to allow the patient
the option of purchasing the capped
rental item, after the thirteenth
month, or continuing with rental
to the fifteenth month. If the
patient selects the purchase option,
rental payments continue through
the thirteenth month, at which
time title to the equipment transfers
to the patient without further
payment of any kind. The patient
then owns the equipment and is
responsible for maintenance and
upkeep.
If the patient chooses to continue
renting, rental payments continue
through the fifteenth month. After
15 months of continuous rental,
payments cease and the supplier
(Health-E-Quip) is allowed to
charge a maintenance fee every
six months. The maintenance fee
is the equivalent to one month's
rental. The supplier retains ownership
of the equipment but is responsible
for all maintenance and upkeep
for as long as medical necessity
continues.
If the patient changes suppliers
during the fifteenth month of
continuous rental, the supplier
providing the equipment on the
tenth month (counting all months
during which the equipment was
provided by a previous supplier)
must allow the patient the purchase
option and collect rental only
through the thirteenth month,
at which time title transfers
to the patient. On the other hand,
if the patient elects to continue
renting, the second or subsequent
supplier receives rental payments
only through the fifteenth month
and is then responsible for upkeep
and maintenance as described above.
NOTE: Because
of this peculiarity in Medicare
policy, most DME suppliers are
cautious about providing items
previously rented from another
supplier.
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