Same and Similar with AFOs

What does “Same and Similar” mean when it comes to DME, specifically regarding Ankle Foot Orthoses, aka AFOs?

• • 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 Non-coverage (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) or

              3. Check via Noridian Healthcare Administrators, LLC Interactive Voice Response IVR

4. Access such information within CGS Administrators, LLC Medicare Portal or Noridian     Healthcare Administrators, LLC Medicare Portal

• • The list is NOT all inclusive and that while every effort is made to keep it current, there may be relationships that might trigger a denial that are not listed.

      Same or Similar Chart

AFO/KAFO          O&P (Orthotics and Prosthetics)                             

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

This is my opinion.

Michael G. Warshaw

DPM, CPC

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