AFO DENIALS BASED ON “SAME OR SIMILAR”

Posted on December 20, 2018 by Alea Becwar

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.

See more about this here: https://www.podiatrym.com/pdf/2019/2/Kesselman219web.pdf

New Billing Codes for Plantar Fascia Night Splints, Pneumatic and Non-pneumatic Walking Casts

Posted on January 28, 2015 by Josh White

Medicare now differentiates between off-the-shelf and custom fitted type prefabricated AFOs including pneumatic and non-pneumatic walkers and plantar fascia night splints.

Traditionally used codes reflect the custom fitted version and the allowable amounts for both are currently the same. For devices traditionally billed using L4360, L4386 and L4396, new codes reflecting the off-the-shelf definition most likely apply.

Click below to read entire article:

NEW BILLING CODES FOR PLANTAR FASCIA NIGHT SPLINTS, 150127

Increased Medicare DME Reimbursement for 2015

Posted on January 28, 2015 by Josh White

Good news!! On January 1, 2015, the Medicare fee schedule for diabetic shoes, Moore Balance Brace and Arizona custom AFOs increased. While the amount reimbursed by each DME MAC may vary slightly, the National Fee Schedule allowables are as follows:

Depth Shoes (A5500) $141.14
Prefabricated, Heat Molded Inserts (A5512) $57.58
Custom Molded Inserts (A5513) $85.92

Depth Shoes w/ 3 pr. Prefab, Heat Molded Inserts $313.88
Depth Shoes w/ 3 pr. Custom Molded Inserts $398.90
Custom Molded Shoes w/ Custom Molded Inserts $586.42

Arizona AFO, Standard (L1940, L2330, L2820) $1162.23
Moore Balance Brace (L1940, L2330, L2820) $1162.23

For a complete listing of updated DME prices, including prefabricated and custom ankle foot orthoses, go to:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html.

What to Do if a Patient Doesn’t Pick Up Their DME Product?

Posted on November 20, 2012 by Josh White

Question:

If a DME product was fabricated and paid by the carrier, but the patient does not come to pick it up despite proper scheduling, what is the responsibility of the podiatrist?

Answer:

Medicare Benefit Policy Manual
Chapter 15 – Covered Medical and Other Health Services

Publication 100-02, Chapter 15, Section 20.3

20.3 – Artificial Limbs, Braces, and Other Custom Made Items Ordered But Not Furnished
(Rev. 1, 10-01-03)
B3-2005.3

A. Date of Incurred Expense
If a custom-made item was ordered but not furnished to a beneficiary because the individual died or because the order was canceled by the beneficiary or because the beneficiary’s condition changed and the item was no longer reasonable and necessary or appropriate, payment can be made based on the supplier’s expenses. (See subsection B for determination of the allowed amount.) In such cases, the expense is considered incurred on the date the beneficiary died or the date the supplier learned of the cancellation or that the item was no longer reasonable and necessary or appropriate for the beneficiary’s condition. If the beneficiary died or the beneficiary’s condition changed and the item was no longer reasonable and necessary or appropriate, payment can be made on either an assigned or unassigned claim. If the beneficiary, for any other reason, canceled the order, payment can be made to the supplier only.

B. Determination of Allowed Amount
The allowed amount is based on the services furnished and materials used, up to the date the supplier learned of the beneficiary’s death or of the cancellation of the order or that the item was no longer reasonable and necessary or appropriate. The Durable Medical Equipment Regional Carrier (DMERC), carrier or intermediary, as appropriate, determines the services performed and the allowable amount appropriate in the particular situation. It takes into account any salvage value of the device to the supplier.

Where a supplier breaches an agreement to make a prosthesis, brace, or other custom-made device for a Medicare beneficiary, e.g., an unexcused failure to provide the article within the time specified in the contract, payment may not be made for any work or material expended on the item. Whether a particular supplier has lived up to its agreement, of course, depends on the facts in the individual case.

There are slight variations in the procedure of each DME carrier and the provider has to call and find out and follow those, but for the most part they are similar to what is outlined below.

According to National Government Services, one of four Medicare DME MACs:

1) Submit a claim with the FULL billing amount you usually bill.
a. Date of Service should be Date of Refusal or Date of Death
2) Include in the narrative section a brief explanation of the situation. Mention that the item ‘has no salvage value and is a complete loss’.
3) After receipt of claim, they may ask for more information such as a receipt of the purchase of the item, explanation of your other related costs such as staff time, your own time, etc. It is their discretion depending on many factors such as How often you have claims such as this, the total amount involved, and other DME history of patient and provider.
4) Based on all this, the carrier will pay whatever they feel is appropriate, even up to the full amount billed or….nothing at all!
5) This decision can be appealed up to the various levels following usual procedures

Be an AFO Expert – It’s Easy if You Use DME Protocols

Posted on August 17, 2012 by Josh White

Time and time again I am asked the same four questions about AFOs:

When should they be used
What’s the correct diagnosis code
What HCPCS code should be used for the AFO
How much does it pay?

While Medicare does not offer definite answers to any of these questions, it does offer guidance in the form of LCDs, Letter of Common Determination and fee schedules.

SafeStep features free webinars on DME Treatment Protocols and another on Compliance. To register, simply click here, http://www commande cialis.safestep.net/Members/WebinarInfo.asp. Recorded versions of presentations can also be found in “Library” section of SafeStep website. Even if you have seen this presentation in the past, it’s worth attending again as codes and requirement continue to change.

In collaboration with leaders of the American Academy of Podiatric Management and other knowledgeable practioners, SafeStep created the DME Treatment Protocols booklet. This guide offers a step by step approach to devices that will effectively work for the most commonly seen biomechanical conditions and offers guidance of how to bill and how much to charge. While not intended to be followed explicated, it offers practioners an effective starting point and way to developer’s ones own approach to care. To get your copy of this valuable guide, cont

Once protocols are established, they should be combined with an effective inventory management routine so that the office is certain to always have in stock products for the most commonly seen condition but not so much inventory as to take up valuable office space. When effectively implemented into office routines, staff should put possible devices out for the doctor to consider so that easily available to discuss with the patient. If indicated for a Medicare patient, the device can be dispensed on the spot, no prior authorization is necessary.

What is the Best Way to Measure Shoe Size for Patients Wearing an AFO?

Posted on May 31, 2012 by Josh White

Most any AFO makes shoe fitting more challenging; the bulkier the device, the harder to fit shoes. The most important concept is the importance of fitting from the inside out. That is, the shoes must accommodate the foot, insert and AFO. Shoe design is as significant as size for effective fitting.

Features of shoes best to fit over an AFO:

Incorporate rocker sole if propulsive gait and AFO limits ankle and STJ sagittal joint motion
Full contact sole that does not taper in midsection.
Firm heel counter that do not twist easily.
Removable footbed
Removable spacers

Shoe styles determined to fit best over AFOs are indicated in the SafeStep shoe catalog and on the website with an AFO icon.

When sized properly:

There should be 1/2″ space between the end of the longest toe and the end of the shoe.
Ensure that the shoes are wide enough such that the foot does not bulge the lateral side.

Fitting will be best accomplished in the office with the use of a display stand or with pairs of shoes to try on. When the fitting is challenging or if one foot is significantly different in size or shape than the other, its best to refer patient to store where shoes can be tried on over AFO.

Fit may be best accomplished by removing spacers from shoe with AFO and adding to shoe without.

If foot with an AFO much larger and different in shape from contralateral side, best option is custom molded shoes made over AFO. Entails first molding for AFO and then for shoes afterwards. Custom shoes are only covered by Medicare for patients with diabetes or if AFO attaches to shoe. Alternatively, Arizona AFO makes a custom shoe with built in brace called the Closed Toe Walker.

Falls are a BIG Problem; Become a Prevention Expert and Watch Your Practice Soar

Posted on April 26, 2012 by Josh White

Josh White, DPM, CPed

One out of three adults age 65 and older fall each year. Falls are a silent killer that most podiatrists simply don’t think much about addressing. Given the scale of the problem and the prevalence of risk factors, developing a specialty in fall prevention presents podiatrists with an opportunity that can significantly benefit their patients and their practice.

Conditions commonly seen by podiatrists and associated with increased risk for falling include:

Foot pain
Ankle weakness
Limited ankle motion
Postural instability
Loss of proprioception
Inappropriate shoe gear

Other risk factors podiatrists should be cognizant of include: dizziness, history of falls or near falls, peripheral neuropathy, impaired balance and drug interactions. If any of these conditions are determined, a more comprehensive fall risk assessment is indicated. See the sample podiatric fall risk evaluation form.

Balance and walking speed gradually decline with age. This is attributable to decreased muscle mass and is exacerbated by reduced activity level. Weakening of the anterior tibialis muscle decreases the body’s ability to maintain balance and may affect the timing of toe clearance during the swing phase of gait. Tripping can result from the toe catching on the floor. Postural sway relates to the constant displacement and correction of the body’s center of gravity over it’s base of support. Decreased muscle strength, particularly with decreased sensation can lead to increased postural sway and increase one’s risk for falling.

No assistive device is as effective at decreasing the likelihood of falls as a walker. Patients though are often resistant to accepting such a device or a cane. Unfortunately, the impetus to use a canes or walker often comes only after a fall occurs. Ankle foot orthoses improve stability by reducing postural sway, increasing sensorimotor feedback and thus improving proprioception. AFOs are only effective when worn and pose patient compliance issues relative to ease of use, impact on shoes that can be worn, comfort and appearance. Fortunately, improved AFO designs fit more easily into shoes, are lightweight, offer ease of closure and still address risk factors that can contribute to increased risk for falling.

Medicare policy makes clear that patients documented to have orthopedic risk factors for falls are covered for custom AFO’s. The Medicare LCD states that to be covered, an item must “be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member”. The Medicare Benefit Policy Manual states that appliances are covered when “used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body.” If biomechanical examination determines any of the following diagnoses to be present, clinical indications demonstrating medical necessity are met:

Muscle weakness (728.87)
Ataxia, muscular incoordination (781.3)
Gait abnormality/ staggering, ataxic (781.2)
Osteoarthritis, localized primary ankle & foot (715.17)
Arthropathy, unspecified, ankle and foot (716.97)
Pain in joint, ankle, foot (719.47)
Instability of joint, ankle & foot (718.87)
Dropfoot (736.79)
Hemiplegia (438.20)

Fall prevention requires a comprehensive approach to care of which custom AFOs may be one component. Based on podiatric fall risk assessment, the podiatrist should consider prescription of primary and ancillary services. Such services and conditions that each may address include:

Physical / Occupational Therapy :

history of falls
sensory deficits
muscle weakness
poor balance

Primary Care:

vestibular abnormalities
medication interactions
history of seizures
history of hypotension

Home Health Care

difficulty leaving the home
Muscle weakness
hearing loss
vision loss

By providing appropriate intervention, podiatrists can assume a leading role in a multidisciplinary approach to care.

Summary

There are some basic steps that podiatrists can take to develop a fall prevention program:

Create awareness within ones’s practice regarding the risk of falls and that the office is committed to offering appropriate preventative care. Consider informational brochures and office posters.
Speak to community groups about the role of intervention to reduce patient risk.
Network with other physicians and specialists including physical therapists, occupational therapists and home healthcare workers to promote a team approach to care.
Perform fall risk assessment and consider use of balance AFO if appropriate risk factors are determined.

There is no simple fall prevention strategy that will work for all patients. As falls result from of a complex interaction of intrinsic and extrinsic risk factors, interventions require a multi-faceted approach. A strong fall prevention strategy that encompasses a number of interventions and targets multiple risk factors is more likely to be successful.