Order and obtain durable medial equipment and supplies

Durable medical equipment (DME)

includes medical devices and supplies that can be used repeatably outside of a hospital

Common examples of DME

those used outside of hospitals are dialysis machines, continuous positive airway pressure (CPAP) machines, oxygen concentrators and ventilators, orthotics and prosethese, bed equipment, mobility aids, and personal care aids

DMEPOS

durable medical equipment, prosthetics, orthotics, and supplies

What is necessary to qualify as a DMEPOS

primarily serve a medical purpose, rx’ed by or ordered by a provider, be able to be used repeatedly, have an expected lifetime of at least three years, be used in the home, only be used to pt, who have an injury or disability

MA responsible for what regarding DMEPOS

assist the provider with these devices and will provide education and support for the patient

What is considered DMEPOS are defined by

Medicare, Medicaid, and other insurance companies- at least fro reimbursement purposes

What isn’t considered DMEPOS

compression leggings, incontinence pads, and ramps installed in the home

For a patient to be eligible for DMEPOS the provider must

order item through a prescription or medical order form to be submitted to a supplier

Provider must state

why DMEPOS is needed for the patient’s condition or injury and is for home use

Some DMEPO items like wheelchair require a

face-to-face encounter, where a visit to the provider is required within 6 months before the order

Face-to-face encounter must be

documented in the pt medical record

The supporting documentation must include

subjective and objective information and information used for diagnosing, treating, and managing the patient’s condition for which the DMEPOS is ordered

Some DMEPOS items what may be required

prior authorization

Centers for Medicare & Medicaid Services (CMS) has established what?

a list of items that are considered DMEPOS called the Master list. in addition a subset list of items requiring prior authorizations - “Required Prior Authorization List”

Prior authorization

process through which a request for provisional affirmation or approval of coverage is submitted for review before a DMEPOS item is furnished to a beneficiary and before a claim is submitted for payment

Some items that require prior authorization include:

power wheelchairs, powered air flotation beds, powered pressure-reducing air mattresses and more

To submit a DMEPOS item for prior authorization, provider will submit

the necessary forms and information to the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for review

If the DME MAC denies prior authorization for the equipment provider can

appeal but must provide more reasons and additional documentation related to why the patient needs the DMEPOS