Article Detail - JA DME

Same or similar denials are a top denial for the Ankle-Foot Orthoses (AFO)/Knee-Ankle-Foot Orthoses (KAFO) policy. This may be due to beneficiaries requiring an AFO/KAFO initially, then later, during the reasonable useful lifetime (RUL), as the beneficiary’s medical condition changes, they require another orthosis to treat the change in medical condition. For example, many beneficiaries initially require a boot and then later move on to a long-term orthosis.

When providing a brace for a change in medical condition, suppliers should obtain an Advance Beneficiary Notice of Noncoverage (ABN) if the previous orthosis has not reached its RUL and submit the claim with the KX modifier when all requirements specified in the policy have been met. When the claim denies as same or similar, appeal the claim, and include documentation justifying the change in medical condition, including all medical records to support the change. Be sure to include the valid ABN with the appeal request.

Note: The KX and GA modifiers may not be appended to the same claim line. This will cause a rejection of the claim for incorrect modifiers.