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+--- Thread: Please verify: DEFINED: "13 months of CONTINUOUS USE" (/Thread-Please-verify-DEFINED-13-months-of-CONTINUOUS-USE)
Please verify: DEFINED: "13 months of CONTINUOUS USE" - soyjer - 08-08-2024
Can someone please verify the accuracy of my statement:
The following Medicare document refers to "13 months", but also refers to "15 months". I believe that this is because, at 10 months, the patient is given a choice between:
1.) 3 more months of rental paid by Medicare, and then patient owns the equipment,
OR
2.) 5 more months of rental paid by Medicare, and then the patient must surrender or buy the equipment.
Medicare's, definition of "13 months of CONTINUOUS USE" can be found here:
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https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c20.pdf
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30.5.4 - Payments for Capped Rental Items During a Period of Continuous Use
"...A period of continuous use allows for temporary interruptions in the use of equipment.
Interruptions may last up to 60 consecutive days plus the days remaining in the rental
month (this does not mean calendar month, but the 30-day rental period) in which use
ceases, regardless of the reason the interruption occurs. Thus, if the interruption is less
than 60 consecutive days plus the days remaining in the rental month in which use ceases,
DME MACs and A/B MACs (HHH) will not begin a new 15-month rental period. Also,
when an interruption continues beyond the end of the rental month in which the use
ceases, MACs will not make payment for additional rental until use of the item resumes.
MACs will establish a new date of service when use resumes. Unpaid months of
interruption do not count toward the 15-month limit.
EXAMPLE: A patient rents an item of equipment for 12 months and is then
institutionalized for 45 days. Upon his discharge from the institution, the patient resumes
use of the equipment and is considered to be in his 13th month of rental (since the period
of institutionalization is not counted) for purposes of calculating the 15-month rental
period. Moreover, for the period he was institutionalized, no payment is made for the
item of equipment. If the supplier desires, it may pick up the item of equipment during
the patient's hospitalization but is required to return the item upon the patient's return
home.
If, however, the interruption is greater than 60 consecutive days (plus the days remaining
in the rental month in which need ceases) and the supplier submits a new prescription,
new medical necessity documentation and a statement describing the reason for the
interruption which shows that medical necessity in the prior episode ended, a new 15-
month period begins. If the supplier does not submit this documentation, a new 15-
month period does not begin.
As a general rule, DME MACs and A/B MACs (HHH) accept written documentation
from suppliers without further development. However, although it is expected that such
circumstances are limited in number, they do represent an opportunity for abuse.
Therefore, if a pattern of frequent interruptions in excess of 60 days occurs, MACs will institute a thorough medical review of the supplier's claims. MACs should reportu qestionable situations to the RO of the Inspector General.
If a 15-month rental period has already ended and a greater than 60 consecutive day
interruption occurs, MACs will subject any claims purporting to be a new period of
medical necessity after the interruption to a thorough medical review to ensure that
medical necessity did in fact end after the prior episode.
Additional issues relating to the term "continuous" follow.
Change of Address
If the beneficiary moves during or after the 15-month period, either permanently or
temporarily, it does not result in a new rental episode.
Modifications or Substitutions of Equipment
If the beneficiary changes equipment to different but similar equipment, DME MACs and
A/B MACs (HHH) may refer the claim to their medical review unit. If, after thorough
review, they conclude that the beneficiary's medical needs have substantially changed and
the new equipment is necessary, DME MACs will begin a new 15-month period. The
supplier providing equipment during the 10th month must also provide the purchase
option. Otherwise, they will continue to count against the current 15-month limit and
base payment on the least expensive medically appropriate configuration of equipment (if
the 15-month period had already expired, they will make no additional rental payments).
The principles are described in the Medicare Benefit Policy Manual, Chapter 15.
If the new configuration is a modification of existing equipment through the addition of
medically necessary features (e.g., a special purpose back is added to a wheelchair),
DME MACs and A/B MACs will continue the 15-month rental period for the original
equipment and begin a new 15-month rental period for the added equipment.
Change in Suppliers
If the beneficiary changes suppliers during or after the 15-month rental period, this does
not result in a new rental episode. For example, if the beneficiary changes suppliers after
his 8th rental month, the new supplier is entitled to the monthly rental fee for seven
additional months (15 - 8). The supplier that provides the item in the 15th month of the
rental period is responsible for supplying the equipment and for maintenance and
servicing after the 15-month period (see §40.2)..."
RE: Please verify: DEFINED: "13 months of CONTINUOUS USE" - SarcasticDave94 - 08-08-2024
I don't recall that the 15 month being mentioned for CPAP. And typically after the 90 day compliance, CPAP isn't strictly monitored, for CPAP device. However, you'll likely need to answer to DME if you're using the CPAP to get them to process insurance billing for supplies.
RE: Please verify: DEFINED: "13 months of CONTINUOUS USE" - Rickyricardo - 08-09-2024
I didn't read the whole screed just what is in bold with the 2 numbered options, but logic says 1) is better than 2) because with 1) you own it (earlier) and don't pay anything at all.
With 2) you lose it or pay for it. In both cases you have it paid for and for at least 13 months. Taking option 1), you still have it at the 13,14 and 15 month mark and pay nothing.
Based on the patient having a choice at 10 months, 2) makes no sense.
RE: Please verify: DEFINED: "13 months of CONTINUOUS USE" - soyjer - 08-09-2024
(08-09-2024, 02:27 AM)Rickyricardo Wrote: I didn't read the whole screed just what is in bold with the 2 numbered options, but logic says 1) is better than 2) because with 1) you own it (earlier) and don't pay anything at all.
With 2) you lose it or pay for it. In both cases you have it paid for and for at least 13 months. Taking option 1), you still have it at the 13,14 and 15 month mark and pay nothing.
Based on the patient having a choice at 10 months, 2) makes no sense.
Yes... unless there is something we are overlooking, the only reason I can think of would be if the patient only planned on using the equipment for just 15 months total, and a rental for those last 3 months would be preferable because lack of ownership = lack of financial responsibility for replacement if it breaks during those last 3 months.
A stretch of an explanation, admittedly. ?