AFO DENIALS BASED ON “SAME OR SIMILAR”

The DME MACs have recently begun strictly enforcing a long-existing policy, “Same or Similar.” This situation has resulted in suppliers more frequently receiving denials for DME, indicated on EOBs with reason code “M3.”

Medicare dictates that AFOs can be dispensed only once, per side, every five years. The “Same or Similar” policy states that a beneficiary cannot get another AFO device for the same limb within this period unless the AFO is lost, stolen, or irreparably damaged or the patient has a new diagnosis, resulting in the need for a new type of device.

AFOs considered to be within the same or similar category include both custom fabricated and off-the-shelf including:

L1900, L 1902, L1904, L1906, L1907, L1910, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1980, L1990, L2000, L2005, L2010, L2020, L2030, L2034, L2035, L2036, L2037, L2038, L2106, L2108, L2112, L2114, L2116, L 2126, L2128, L2132, L2134, L2136, L4350, L4360, L4361, L4370, L4386, L4387, L4396, L4397, L4398, L4631.

For example, a patient receiving a CAM Boot (L4386) in 2017 for a stress fracture on the left foot would likely be rejected for a Custom Fabricated Hinged AFO (L1970) should he or she require one for Posterior Tibial Tendinosis of the left foot in 2019.

Details of the policy can be found at https://med.noridianmedicare.com/web/jadme/policies/lcd/active.

The rule is not provider-specific, meaning that if a patient received an AFO from another provider or supplier within the past five years that was billed to Medicare, the claim for a “same or similar” device may be denied.

What to do about it

Providers can easily discover whether their patient has received a device within the past five years by enrolling in their respective DME MAC Jurisdiction’s Provider Portal. Information on enrolling in the provider portals is available on each DME MAC Homepage.

APMA urges its members not to use the NMBI (National Medicare Beneficiary Identifier) and to continue to use the patient’s Social Security-linked number as there are cases in which the provider portal either will not recognize the NMBI or cannot properly perform a “Same or Similar” inquiry. This issue has been brought to the attention of CMS contractors. Once this issue is resolved, APMA will notify our members.

Once enrolled in a DME MAC carrier’s portal, it will take a minute or less to determine what, if any, devices your patient has received in the last five years. The provider portal will provide you with information regarding the date, HCPCS codes, and name of the supplier who provided the previous device.

The Noridian Provider Portal will only provide “Same or Similar” information regarding services provided in Regions A and D, while MyCGS will only provide “Same or Similar” Information for services provided in Regions B and C.

APMA suggests that providers confirm their patient’s legal address history. This information will minimize any possibility that services were provided previously in a different DME MAC Jurisdiction.

APMA urges members to save any information received on the provider portal. Be sure your chart documentation includes the above information and, if dispensing another AFO for the same side within five years, the fact that a new device is required for one of the several reasons stipulated in the LCD. These reasons include, but are not limited to: The device was lost, stolen, irreparably damaged (due to a one-time event); a different diagnosis; change in anatomy (e.g., amputation, significant weight loss or gain) resulting in the previous device being unusable by the patient; or a different physiologic need (e.g., previous device was for a non-weight-bearing situation and the new device is for a weight-bearing situation).

Suppliers may still initially receive a “Same or Similar” rejection. However, a properly documented progress note including the above information may be used to successfully appeal (Redetermination) a “Same or Similar” rejection.

Providers may obtain the redetermination form from their DME MAC Website and/or provider portal. Once this form is downloaded and completed, you may scan the form (or complete and save it online) and then upload the form and other pertinent information, including response letter and your chart documentation, directly onto the DME MAC provider portal.

By using the provider portal, you may avoid fax transmission errors and be instantly assured that the information submitted has been received by the DME MAC. You may also follow the appeals process via the provider portal and read any comments made by the nurse reviewer. While a redetermination must be completed within a 90-day period (once received by the carrier), it will typically take only 30 days using the provider portal.

Providers may wish to obtain a properly executed ABN, should your search of the provider portal result in a potential “Same or Similar” scenario. A properly executed ABN should be specific as to why your services (new device) may not be covered. Information to include in the ABN should include the name of the device dispensed, date of service, name of supplier, and that any new device may result in a “Same or Similar” rejection.

Recent communication between APMA and the DME MAC Medical Directors seems to indicate that the DME MACs are interested in developing new edits to substantially reduce the number of “Same or Similar” rejections.

This situation is fluid, and APMA urges members to monitor APMA.org for future developments.

Reference: APMA.org

SafeStep representatives can help you:

  • Register for Medicare portal
  • Easily check patient eligibility prior to prescribing AFOs
  • Submit claims for redetermination (appeal) either via Medicare carrier website or via fax.

Contact us at info@safestep.net or 866.712.STEP

How To Integrate DME Into Treatment Protocols – Part 1

Having established treatment protocols for common conditions one sees in practice can go a long way toward reining in costs and maximizing efficiency. In this 7 part series, I will offer insights on the benefits of these protocols and how to incorporate durable medical equipment (DME) into the equation.

A key impetus for reining in health care costs is based on the understanding that 50 percent of these costs go toward unnecessary administrative costs, excessive or unnecessary tests and other waste.

Increasingly, large healthcare delivery systems are racing to reorganize their approaches to care as part of their ongoing efforts to rein in costs. Change can be difficult even when the benefits are obvious and the required actions are not complicated. For example, a tremendous amount of infection is still the result of health care professionals not employing well-documented hand washing procedures.

Integral to this reform effort is the creation of practice protocols. An example of integrating practice protocols on a large scale comes from Intermountain Healthcare, which serves patients in Idaho and Utah.1 It determined that 90 percent of its caseload involves the treatment of 70 different conditions. For the majority of these conditions, Intermountain settled on established treatment approaches supported by robust scientific evidence.

Intermountain officials understood that the recommended standardized approach is usually appropriate when patients present with one of the 70 conditions though the standardized approach does not apply in every instance.1 Such an approach allows for more consistent delivery of care, more predictable outcomes, better defense in the event of medical malpractice accusation, more consistent billing practices and more accurate documentation.

Four Pertinent Principles In Streamlining Health Care Delivery

Podiatrists can learn from Intermountain’s efforts to streamline its approach to care by adopting four key principles.

1. Manage the care. Select the most common conditions and settle on a treatment approach. The successful adaptation of treatment protocols requires acceptance by all members of the service chain. Applying evidence to practice requires standardization not just of operational routines but of the rules for making clinical decisions. The more detailed the descriptions in a series of tasks, the less decision making along the path and the more predicable the actions and the outcome. One must identify and address every symptom, observations and lab result.

2. Corral variability. Create mechanisms for addressing instances when the standardized approach is not appropriate or not successful. There are instances in which the presenting conditions are complicated, poorly understood and do not fit into expected protocols.

It is essential that practitioners have a way of addressing such instances and not continue in a way that is not predictable. Such an approach may entail alternative protocols, further testing or referral to an expert in the field. It is important to examine the incidence and reasons for conditions that fall outside of established protocols.

3. Reorganize resources. When practices redesign clinical protocols, they must also reconfigure the supporting infrastructure and routines. There must be a match of the staff, incentive systems, information technology (IT) systems, physical layout of the clinic and educational materials, all with the redesigned process in mind. When a practice does not adopt such a unified approach, podiatrists continue to perform work that they could delegate to medical assistants. Performance measures then remain focused on factors not critical to achieving desired outcomes.

It is essential that medical staff members receive training and stay up to date with educational materials and tools for each protocol. As the saying goes, “If you cannot measure it, you cannot manage it.” There must be mechanisms in place to determine if the staff is performing the desired procedures and mechanisms should be in place to ensure that this is the case. Determine the time, personnel and materials necessary for each approach.

4. Learn from everyday care. Continually monitor the results of the practice’s approach and integrate the lessons learned from cases when the standardized approach is not successful.

The structure and processes of the clinic must allow learning from the everyday work. The people designing the practice protocols must learn from every member performing the various tasks. The people designing the protocols must understand the demands for every service as well as how one performs the task. Such an approach will enable allocation of resources to best meet expected demand. Office managers should do ongoing reviews of charts to ensure that the practice is following treatment protocols and documentation is in order.

The Times of Our Lives

Being a supplier of Medicare Durable Medical Equipment entails a long list of ever changing deadlines and timeframes.  While it may seem difficult to keep track of them all, failure to keep abreast can easily result in claims denials and even exclusion from the program.  In order to help suppliers keep fitting and getting paid, the following are dates and timeframes that all should be familiar with.

  • January 1: Every patient eligible for new shoes if documented need for replacement
  • 3 months: Time allowed from when certifying physician signs certifying statement to when shoes must be fit.
  • 3 months: ADA recommended frequency for comprehensive diabetic foot exam for patients of foot risk category 3 (history of ulceration, amputation)
  • 6 months: Amount of time condition requiring stabilization could justify utilization of custom made AFO.
  • 6 months:  Time prior to fitting shoes that patient needs to have been seen by the physician managing their diabetes
  • 6 months: ADA recommended frequency for comprehensive diabetic foot exam for patients of foot risk category 2 (neuropathy present)
  • 1 year: Interval when Medicare DME supplier number will become inactivated if no DME if billed to Medicare. Reactivation required resubmission of supplier application.
  • 1 year: ADA recommended frequency for comprehensive diabetic foot exam for patients of foot risk category 0 (No neuropathy, protective sensation intact)
  • 3 years: Interval when Medicare DME suppliers must have supplier information revalidated. Registration every three years requires payment of $505 payment and may entail visit from inspector.
  • 3 -5 years: Amount of time custom made durable medical equipment is expected to last unless there is change in patient’s condition such that there is justified new reason of “medical necessity”
  • 2030: Time by which Medicare population is expected to double versus 2000 levels*

*MedPAC Report to Congress: Promoting Greater Efficiency in Medicare, June 2007. Washington DC: Medicare Payment Advisory Commission, June 2007.