Knowledge Base Article

Q:

Sometimes patients are provided with orthoses they will carry home with them (such as a back brace) while they are an inpatient in the hospital. How do we determine if the hospital absorbs the cost of the orthosis or if the DME company can bill the patient’s Medicare?

A:

Medicare provides good information about this in the Fact Sheet Provider Compliance Tips for Spinal Orthoses. For orthoses provided to patients before or during an inpatient stay, the key is whether the patient will be using the orthosis for medically necessary treatment or rehabilitation during the inpatient stay. Payments for orthoses are included in payments to hospitals if the patient uses the orthosis during the admission. In these situations, the supplier should not submit claims to the DME MAC. The applicable situations are stated as follows in the Fact Sheet:

• The supplier provides the orthosis to the beneficiary prior to an inpatient admission or Part A covered SNF stay and the medical necessity begins during the stay (for example, after spinal surgery)
• The supplier provides the orthosis to the beneficiary during an inpatient stay prior to discharge and the beneficiary uses the item for medically necessary inpatient treatment or rehabilitation.

However, if the orthosis is given to the patient for home use within two days prior to discharge and is not used during the hospitalization, then the DME may bill the patient’s Medicare. Per the Fact Sheet, “Payments for spinal orthoses are eligible for coverage by DME MACs if the orthosis is medically necessary for a beneficiary after discharge from a hospital or Part A covered SNF stay and the supplier provides the orthosis to the beneficiary within two days prior to discharge home, and the orthosis is not needed for inpatient treatment or rehabilitation, but is left in the room for the beneficiary to take home.”