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Linda Collins Blogger

Providing Back Braces to a Patient in a Hospital

Posted by Linda Collins | May 17, 2017

When a patient is in a hospital or skilled nursing facility (SNF), most services are included in the payment to the facility. This includes all orthotic devices used by the patient during the stay.  

Payment for a spinal orthosis is included in the payment to a hospital or SNF if:

  1. The orthosis is provided to a patient prior to an inpatient hospital admission or SNF stay; and
  2. The medical necessity for the orthosis begins during the hospital or SNF stay (e.g., immediately after spinal surgery).
  3. The patient uses the item for medically necessary inpatient treatment or rehabilitation.

In these situations, you may not submit a claim to the DME MAC. The facility is financially responsible for the cost of the device. This includes delivering a brace to a patient prior to surgery even if it intended for use after the surgery. Remember, the delivery date becomes the date of service.

You may bill the DME MAC for a spinal brace when:

  1. The orthosis is medically necessary for a patient after discharge from a hospital or SNF stay; and
  2. The orthosis is provided to the patient within two days prior to discharge to home; and
  3. The orthosis is not needed for inpatient treatment or rehabilitation.

This is known informally as the "48 hour rule." You must document the delivery date, the date of discharge and the physician's notes must indicate the brace will be used exclusively at home.

What Does this Mean for You?

Check the HCPCS list here.  Click on "2017 Part A MAC Update" and then "2017 Annual SNF Consolidated Billing HCPCS."

If an item is not listed, then it is considered to be a part of the SNF daily rate and is the financial responsibility of the SNF. You may submit an invoice to the SNF and request payment directly from the facility in this situation. The HCPCS codes listed on the spreadsheet are excluded from the SNF payment. In this situation, you may provide the product, document the medical necessity, and submit a claim directly to the MAC for your region.

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