REIMBURSEMENT PAGE
If all of these criteria are met and you bill under the two-day rule, date of service is the patient’s discharge date from the hospital or SNF, and not the date of actual delivery. While the two-day rule allows you to use the date of discharge as your date of service, the actual date of delivery should be documented in the patient’s chart in case questions arise in the future. You also may want to get a verification in writing from the hospital or SNF of the patient’s anticipated discharge date; this will become handy, especially if the patient’s discharge date changes. The purpose of the two-day rule is not to alleviate or shift the responsibility of the hospital or SNF to provide its patients with appropriate care and medically necessary services. If an orthosis or prosthesis, or any other type of O&P device or service, is needed as part of the patient’s recovery or rehabilitation in the facility, it must be paid for by the facility regardless of when it was delivered. To learn more about this rule, including the responsibilities of the hospitals or SNFs, review Chapter 20, Section 110.3, of the Medicare Claims Processing Manual.
Items Ordered Prior to an SNF Stay
IMAGE: iStock.com/sturti
The next exemption regarding when your date of delivery will not equal your date of service also is fairly common, but its scope is much narrower than that of the two-day rule. There may be instances when an item is ordered when a patient is in a Part A hospital stay, but you are unable to deliver the item until the patient is discharged to a Part A SNF stay. Alternatively, an item is ordered while the patient is at home but is delivered while the patient is in an SNF Part A stay. We will focus on the latter, as it is the instance where your date of service or date of delivery on your claims will be altered. If a custom orthosis or prosthesis is ordered while a patient is at home, the medical need for the item has been established before the patient was admitted to the SNF. So, if the custom
orthosis or prosthesis (or even an item or service not exempt from SNF billing) was ordered while the patient was at home but it was delivered to the patient in an SNF, you may bill Medicare. However, you must alter your date of service; if you use the date of delivery as your date of service, Medicare will deny the claim, indicating that it is not the payor of record because the SNF has already been paid for the item/service under its prospective payment system bundled payment. So, what is your date of service? Your date of service would be the start date of the order, or the date you began treating the patient. All of the scenarios in this article apply only to custom orthotic items and prosthetic items, and do not apply to prefabricated items or diabetic shoes. This is because of the extra time required to fabricate and provide a custom item. The basis of this narrow exemption was established by the MLN Matters article SE0507, “Prosthetics and Orthotics Ordered in a Hospital or Home Prior to a Skilled Nursing Facility Admission,” which was revised in March 2013 and can be found on the CMS website, www.cms.gov.
Refused Items
There is another common scenario when date of service may differ from actual date of delivery: when an item is not delivered at all because it has been refused. An orthosis or prosthesis is traditionally considered to be refused if the patient no longer requires the item because the item is no longer medically necessary. The change in medical necessity, or refusal, may be the result of a change in a patient’s condition. This may occur, for example, if you are going to provide a patient with a thoracic lumbarsacral orthosis (TLSO), but before you are able to deliver the TLSO, the patient and physician decide on a different course of treatment. Since the patient chose a different means of treatment, the TLSO may no longer be needed, or medically necessary. The device has now been refused. Similarly, if a patient dies before you are able to deliver the device, it is no longer medically necessary, and the device is refused. Once you are aware that a patient has refused a device, or the device is no longer medically necessary, document the date you learned of the refusal. The date you learned about the refusal, or O&P ALMANAC | MARCH 2016
19