Summary of Changes:

• Purpose: Update the denial liability for DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) claims that overlap inpatient hospital stays from patient responsibility to contractual obligation.
• Effective Date: July 1, 2024.
• Implementation Date: July 1, 2024.

Manual Instructions:

• There are no changes in the manual instructions for this CR.

Funding:

• This CR serves as technical direction for Medicare Administrative Contractors (MACs). Contractors should not incur costs beyond those allotted in their contracts without specific authorization.

General Information:

Background:

• Previous CR 8844 established an Informational Unsolicited Response (IUR) process for DME items provided during a Part A hospital inpatient stay, assigning liability to the patient.
• CR 7189 instructed contractors to assign liability to the provider when a CWF (Common Working File) reject was returned for DMEPOS provided during an inpatient stay.
• CR 13631 aims to align these instructions, assigning liability to the provider consistently, as payment for DMEPOS during inpatient stays is included in hospital reimbursement.

Policy:

• No changes in policy.

Business Requirements:

1. Contractors must use specified remittance advice and MSN (Medicare Summary Notice) messages to deny claims for DMEPOS items provided during inpatient stays.
   • Reason Code 97: Service included in payment/allowance for another service.
   • Remark Code M2: Not paid separately when the patient is an inpatient.
   • Group Code CO (Contractual Obligation)
   • MSN 8.46: Payment included in allowance for another service.
2. Contractors must adjust claims with incorrect liability when notified.

Provider Education:

• CMS will release national provider education content via the MLN Connects® newsletter. MACs should link this information on their websites and distribute it to providers.

Supporting Information:

• No additional recommendations or supporting information provided.

Contacts:

• Post-implementation contacts are the Contracting Officer’s Representatives (COR).

Funding for MACs:

• Contractors are to consider this as technical direction and notify the Contracting Officer if any part of the directive is outside the current scope of work.