CMS Pub. 100-04, ch. 20, § 30

NOTE: CMS seeks to reduce burden and modernize processes to ensure a reduction in

improper payments and an increase in customer satisfaction. The Certificate of Medical

Necessity (CMN) form and DME Information Form (DIF) were originally required to

help document the medical necessity and other coverage criteria for selected Durable

Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items. In the past, a

supplier received a signed CMN from the treating physician or created and signed a DIF

to submit with the claim. Due to improvements in claims processing and medical records

management, the information found on CMNs or DIFs is available either on the claim or

in the medical record and is redundant. Therefore, to reduce burden and increase

customer satisfaction, providers and suppliers no longer need to submit these forms for

services rendered after January 1, 2023.

• For claims with dates of service on or after January 1, 2023 – providers and

suppliers no longer need to submit CMNs or DIFs with claims. Due to electronic

filing requirements, claims received with these forms attached will be rejected and

returned to the provider or supplier.

• F or claims with dates of service prior to January 1, 2023 – processes will not

change and if the CMN or DIF is required, it will still need to be submitted with

the claim, or be on file with a previous claim.

This statement applies throughout the Program Integrity Manual wherever CMNs and

DIFs are mentioned.

B3-5102

DMEPOS are categorized into one of the following payment classes:

• Inexpensive or other routinely purchased DME;

• Items requiring frequent and substantial servicing;

• Certain customized items;

• Other prosthetic and orthotic devices;

• Capped rental items; or

• Oxygen and oxygen equipment.

The CMS determines the category that applies to each HCPSC code and issues

instructions when changes are appropriate. See §§130 for billing information for each

payment class.

DME, including DME furnished under the home health benefit and Part B DME benefit,

is paid on the basis of the fee schedule.

Oxygen and oxygen equipment are paid on the basis of a fee schedule.

Any DME or oxygen furnished to inpatients under a Part A covered stay is included in

the SNF or hospital PPS rate. When an inpatient in a hospital or SNF is not entitled to

Part A inpatient benefits, payment may not be made under Part B for DME or oxygen

provided in the hospital or SNF because such facilities do not qualify as a patient's home.

The definition of DME in §1861(n) of the Act provides that DME is covered by Part B

only when intended for use in the home, which explicitly does not include a SNF or

hospital. (See the Medicare Benefit Policy Manual, Chapter 15). This does not preclude

separate billing for DME furnished after discharge.

Payment to providers and suppliers other than Home Health Agencies (HHAs) for

supplies that are necessary for the effective use of DME is made on the basis of a fee

schedule, except that payment for drugs is made under the drug payment methodology

rules (See Chapter 17 for drug payment information.)

Payment for prosthetics and orthotics is made on the basis of a fee schedule whether it is

billed to the A/B MAC (A), (B), or (HHH), or DME MAC.

Payment under Part B for surgical dressings is made on the basis of the fee schedule

except:

• Those applied incident to a physician's professional services;

• Those furnished by an HHA; and

• Those applied while a patient is being treated in an outpatient hospital

department.