“We had a patient that was dispensed an ankle foot orthoses (AFO) about 4 1/2 years ago. This device broke and he was having difficulty walking without it. We dispensed a new AFO and it was denied as the original wasn’t 5 years old. We had a very long telephone conversation with Medicare along with the patient and his attorney. Unfortunately, Medicare wouldn’t budge as they said he should have gone back to the provider of the original brace, even though it was in another state. We did have an ABN, but the patient said that he’s not going to pay for the replacement. We are working with him now to at least get our lab costs. Unfortunately, appeals don’t always work. We requested a peer-to-peer, but after several months we have not heard anything as they are too backlogged! I suspect that there are other stories like this out there. I wish we could just tell patients what it costs and they hand over their credit cards.”
Unfortunately this is an ongoing, repetitive situation that occurs whenever an AFO is dispensed and fitted and after the fact it was discovered that the patient received a “same or similar” device 4 1/2 years prior. To make matters even worse, the patient did not receive the original AFO in the same state. The original device broke and the patient is having a hard time functioning without it.
It comes down to the number one reason that AFOs are not reimbursed in the world of Traditional Medicare. That reason is the “Same or Similar” policy.
As I have stated several times previously, right off the bat, it is important to note that it doesn’t matter if the original AFO was provided by a supplier/provider in the same town, the same state, the same Durable Medical Equipment Regional Carrier, of which there are two (ie. CGS Administrators, Noridian Healthcare Solutions), or for that matter, by a different Durable Medical Equipment Regional Carrier than the one in your region.
Same or Similar:
• Prior to providing a new item, and to gain the necessary information required (has there been a change in beneficiary’s medical condition that supports need for a different type of similar item or if it has been lost, stolen, or irreparably damaged) to determine whether an Advance Beneficiary Notice of Noncoverage (ABN) should be obtained or not, it is best to:
• Verify that a beneficiary has/has not had a same or similar item
• If he/she has not, bill claim without ABN (no ABN is necessary)
• If he/she has, determine if item has reached its specific reasonable useful lifetime (RUL). For AFOs, it is 5 years.
• If it has, bill claim without ABN (no ABN is necessary)
• If it has not, obtain an ABN and bill claim with applicable modifier
• Verification options include:
1. Ask beneficiary
2. Check via CGS Administrators, LLC Interactive Voice Response (IVR) and Noridian Healthcare Solutions, LLC Interactive Voice Response (IVR)
3. Access such information within CGS Administrators, LLC Medicare Portal and Noridian Healthcare Solutions, LLC Medicare Portal
Here is the same or Same or Similar Chart:
L1900, L1902, 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, L2126, L2128, L2132, L2134, L2136, L4350, L4360, L4361, L4370, L4386, L4387, L4396, L4397, L4398, L4631
What would I do? I would check as I have suggested above. If the second brace that is dispensed is “same or similar,” I would charge the patient the amount that was entered on the Advance Beneficiary Notice of Non Coverage (ie. ABN). That is the whole idea behind having a signed and completed ABN. This is the only option for being reimbursed for the service rendered that was not covered. If the provider, for whatever reason cannot collect from the patient the amount that the patient agreed to by signing the ABN due to the fact that the patient refuses to pay, then the provider needs to decide the next course of action to take. Unfortunately, this would be the only option. Until there is a change in the rules and regulations that are mandated by “same or similar,” the patient is the responsible party.
This is my opinion.
Michael G. Warshaw
DPM, CPC
THE 2022 Podiatry Coding Manual is now available in either Book or Flashdrive formats. It has been completely updated including the E/M coding changes. Many offices across the country consider this to be their “Bible” when it comes to coding, billing and documentation. The price is still only $125 including shipping! To purchase, access the website drmikethecoder.com.
No credit card? No problem! Just send a check for $125 to the following address:
Dr. Michael G. Warshaw
2027 Bayside Avenue
Mount Dora, FL 32757
Are you in compliance with Medicare concerning your billing, coding and documentation? An audit should never be more than an inconvenience. It should not be a life altering event. Find out your status before you are audited by your Medicare carrier. Drmikethecoder special: Have 5 dates of service audited for $250 (new clients only). Contact drmikethecoder.com for more information.
Read Comments