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

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.

Effect of Sequestration on DME

Posted on April 1, 2013 by Josh White

Question: Does the 2% payment reduction under sequestration apply to the payment rates reflected in Medicare fee-for-service fee schedules or does it only apply to the final payment amounts?

Answer: Payment adjustments required under sequestration are applied to all claims after determining the Medicare payment including application of the current fee schedule, coinsurance, any applicable deductible, and any applicable Medicare Secondary Payment adjustments. All fee schedules, Pricers, etc., are unchanged by sequestration; it’s only the final payment amount that is reduced.

Question: How is the 2% payment reduction under sequestration identified on the electronic remittance advice (ERA) and the standard paper remittance (SPR)?

Answer: Claim adjustment reason code (CARC) 223 is used to report the sequestration reduction on the ERA and SPR.

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.

Coding Alert!

Posted on July 30, 2012 by Josh White

Medicare’s Pricing, Data Analysis and Coding (PDAC) has revised it’s original review of the Moore Balance Brace and determined the HCPCS codes to use for billing to be:

L1940 – ankle foot orthosis, molded to patient, plastic
L2820 – addition to lower extremity orthoss, soft interface for molded plastic, below knee section
L2330 – addition to lower extremity orthosis, lacer molded to patient model, for custom fabricated orthoses only.

The 2012 maximum allowable fees for these codes are:

L1940 $571.10
L2820 $100.28
L2330 $453.44

Medicare fees vary by state so go to www.dmepdac.com to determine the specific allowable amounts for your patients.

The Moore Balance Brace is commonly prescribed bilaterally to address risk factors contributory to increased risk of falling. Frequently determined diagnoses that might benefit from the stability afforded by the MBB include:

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)

Click Here for information on how you can incorporate a fall prevention program in your practice, or register for a free informational webinar!

For additional information about the Moore Balance Brace and fall prevention please contact SafeStep at 866.712.STEP (7837) or email info@safestep.net.

PDAC Certification Letter

Medicare Billing for Patients with Two Different Shoe Sizes

Posted on July 17, 2012 by Josh White

Question:
A patient needs to have two different sized shoes–one 13, and one 14. I will be charged extra for this and wonder how I’m to pass this charge on. Can I bill the patient?

Answer:
Additional cost incurred by fitting (I assume Medicare) patient with two different size shoes cannot be passed onto patient (assuming that you accept assignment). If you do not accept Medicare assignment you can charge patient whatever you want such that increased cost is borne by patient. Less significant differences in foot size (especially in width) can sometime be accommodated with the same size shoe by removing spacers from the larger foot and adding spacers to the smaller foot. domain search availability Alternative, if size is significant enough is to cast patient for custom molded shoes.

Josh White, DPM, CPed
joshwhite@safestep.net