AMARILLO, TX – Determining the date of service (“DOS”) for DME is dependent on the type of delivery method utilized. The DOS for DME delivered in-person to a beneficiary is the date the beneficiary received the DME. If the DME is mailed or shipped to the beneficiary, then the DOS is either the shipping date or date of delivery.
Chapter 5, Section 5.2.6 of Centers for Medicare & Medicaid Services’ (“CMS”) Medicare Program Integrity Manual sets forth the guidelines on DME supply refills. CMS requires DME suppliers to contact a beneficiary prior to dispensing a refill to an original order/prescription. The supplier must contact the beneficiary no sooner that 14 calendar days prior to the delivery/shipping date. If the beneficiary authorizes a refill, then the supplier must deliver the DME “no sooner than [10] calendar days prior to the end of usage of the current product.” The DME MACs will allow claims to be processed for refills delivered/shipped prior to a beneficiary’s supply being exhausted.
However, the Local Coverage Determination (“LCD”) and supplemental policy article for CGMs state that CMS’s refill requirements do not apply to CGM supplies. Under the LCD, suppliers must bill under HCPCS code K0553 for CGM supply allowance.
Only a one-month supply allowance or one Unit of Service may be billed at time to the DME MACs. When billing under K0553, the supplier must deliver enough quantities of the supply to last for 30 days following the DOS on the claim.
A supplier may not bill more than one Unit of Service every 30 days. Thus, the supplier is required to monitor the beneficiary’s usage of the supplies. If the supplier learns that there are insufficient supplies to last 30 days, then additional supplies must be provided before the supply allowance is billed. Finally, the LCD policy article also states that the supplier “does not have to deliver supplies used with [CGMs] every month in order to bill code K0553 every month.”
Thus, the DOS for CGMs plays a minor role on how the CGM refills are billed because CGMs are not bound to CMS’s refill requirement. Instead, the DME supplier may only bill for CGM refills every 30 days following the DOS on the claim. For example, if the DME supplier initially ships the CGM supplies on May 1, 2021, the supplier may ship additional supplies on May 30, 2021; however it will still not be able to bill for the CGMs until May 31, 2021. The DME supplier does not necessarily have to deliver the supplies in order to bill for the refill. Rather, the Company needs to monitor the beneficiary’s usage of the supplies and may bill for the refill every 30 days. Best practice then dictates that the supplier should follow up with the beneficiary to ensure that the beneficiary has a sufficient 30-day supply.
Jeffrey S. Baird, JD, is chairman of the Health Care Group at Brown & Fortunato, PC, a law firm with a national health care practice based in Texas. He represents pharmacies, infusion companies, HME companies, manufacturers and other health care providers throughout the United States. Mr. Baird is Board Certified in Health Law by the Texas Board of Legal Specialization and can be reached at (806) 345-6320 or [email protected].
