Prosthetic Coverage by Medicare when you are admitted to a Skilled Nursing Facility (Nursing Home):

When a Skilled Nursing Facility (SNF) admits a Medicare patient, the patient is eligible for up to 100 days of Medicare Part A coverage, provided that certain preadmission and medical necessity criteria are met. During a Part A covered stay, the SNF is reimbursed a daily rate (per-diem), which is based on the patient's anticipated level of care and assignment to a Resource Utilization Group (RUG).

Under this reimbursement system, a SNF is obligated to provide all necessary services and supplies to each Medicare inpatient, with the exception of certain services. When SNF reimbursement rates are set by Medicare, a small portion of each payment is set aside to compensate for orthotics (braces), prosthetic "soft goods", Durable Medical Equipment (DME) and supplies, whether or not the patient actually receives these services. Although the SNF cannot bill a separate line item or L-code for these services, it has, in effect, been paid for them as part of its RUG payment.

Most Prosthetic Codes Are Reimbursed by Part B:

Medicare recognizes that the cost of prostheses often exceed the nursing home's daily rate or RUG payment. Therefore, most definitive prosthetic base codes and components are exempt from this RUG, or lump sum, SNF payment, and may be directly billed to Medicare by the prosthetic company (Optimus). These prosthetic codes represent most definitive prosthetic devices. However, the list of codes does not include items such as immediate post-surgical prostheses or prosthetic socks or shrinkers.

So, in summary, a friend or loved one does not have to wait 100 days until his/her prosthetic care can start in order to be covered by Medicare. This is sometimes confused by a Skilled Nursing Facility and they will not call a prosthetist until after the 100 days of a patient's Medicare Part A coverage is up, and the patient is then on Medicare Part B coverage. The SNF erroneously thinks that they would have to pay for the prosthesis within the first 100 days. This is not the case, and Optimus Prosthetics can bill Medicare directly for most definitive prostheses and not have to bill the Skilled Nursing Facility. So, let's get that prosthetic rehab going!