Article Detail - JA DME
How to Prevent and Address Same and Similar Denials
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) claims often result in denials when the billed equipment or item is deemed the "same as" or "similar to" what the beneficiary already possesses as indicated in claim history, particularly if it falls within the Reasonable Useful Lifetime (RUL). Suppliers encountering such denials can take specific steps to address them effectively.
Key Considerations Before Replacement
Before proceeding with any equipment or item replacement, suppliers should assess the following:
- Change in Medical Condition: Has there been a significant change in the beneficiary’s medical condition that warrants a new item? Ensure the medical record substantiates the change in medical condition for the replacement item.
- Loss, Theft, or Irreparable Damage: Has the original item been lost, stolen, or irreparably damaged? The Standard Documentation Requirements Article A55426 states:
- The definition of replacement is found in the Medicare Benefit Policy Manual (CMS Pub. 100-02), Chapter 15, Section 110.2.C. That section generally defines replacement as the provision of an entirely identical or nearly identical item when it is lost, stolen or irreparably damaged.
- Beneficiary-owned items or a capped rental item may be replaced in cases of loss or irreparable damage. Irreparable damage may be due to a specific accident or to a natural disaster (e.g., fire, flood). Contractors may request documentation confirming details of the incident (e.g., police report, insurance claim report).
- The definition of replacement is found in the Medicare Benefit Policy Manual (CMS Pub. 100-02), Chapter 15, Section 110.2.C. That section generally defines replacement as the provision of an entirely identical or nearly identical item when it is lost, stolen or irreparably damaged.
- History of Same or Similar Items: Has the beneficiary previously received a "same as" or "similar" item? Suppliers should verify these details using the Same or Similar functionality in the Noridian Medicare Portal (NMP).
It is important to note that the NMP will confirm that a beneficiary either has or has not had a same or similar item with Jurisdictions A and D. It is the supplier’s responsibility to check other jurisdictions for same or similar if there is reason to believe that the beneficiary may have obtained a same or similar item within a different jurisdiction. The claims in the NMP are specific to each jurisdiction so each Jurisdiction, JA and JD, may need to be verified along with other jurisdiction’s portals for same or similar.
Note: Some HCPCS codes may be updated when a temporary code is deleted. If the deleted code is not searched for during a same or similar inquiry, it could result in a denial. For instance, the deletion of code K0554 and the introduction of code E2103 exemplify this need for thorough searches. Ensure that all relevant HCPCS codes are entered when conducting searches in the NMP to avoid potential denials.
Answering the above questions will help determine whether an Advance Beneficiary Notice of Noncoverage (ABN) is necessary.
- No Previous History of Similar Item: If there is no previous history of a "same as" or "similar" item, suppliers can bill the claim without obtaining an ABN.
- History Exists, but RUL Reached: If a history of a "same as" or "similar" item exists, determine if the item has reached the RUL. If it has, the claim can be billed without obtaining an ABN.
- RUL not Reached: If the item has not reached the RUL, suppliers should obtain an ABN and proceed with billing the claim while applying the appropriate modifier.
Addressing Denials
When a DMEPOS claim is denied due to equipment/item similarity, suppliers may want to consider initiating an appeal/redetermination request. This appeal must include thorough documentation to support the replacement item, which may involve:
- Evidence of Loss, Theft or Irreparable Damage: If applicable, provide documentation supporting that the original item was lost, stolen, or sustained irreparable damage.
- Medical Records: Include records from the prescribing physician or practitioner that indicate a change in the beneficiary’s medical condition, underscoring the necessity for a different item.
- Advance Beneficiary Notice of Noncoverage (ABN): Include a valid ABN when one was obtained prior to providing the item.
This documentation is crucial when appealing the claim to justify the need for an item that is the "same as" or "similar to" what the beneficiary already has been provided.
Resources
Suppliers can access additional guidance and instructions on managing ABN requirements and using the Same or Similar functionality through the following resources:
