Same or Similar Chart - JA DME
Same or Similar Chart
Replacement
The definition of replacement is found in CMS Internet Only Manual (IOM), Publication 100-02, Benefit Policy Manual, Chapter 15, Section 110.2.C. That section generally defines replacement as the provision of an entirely identical or nearly identical item when the original item is lost, stolen, or irreparably damaged. Further direction on replacement is included in the Standard Documentation Requirements Article (A55426) on the CMS website.
Replacement of items due to irreparable wear takes into consideration the Reasonable Useful Lifetime (RUL) of the item. The RUL for durable medical equipment (DME) is determined through program instructions. In the absence of program instructions, Medicare Administrative Contractors (MACS) may determine the RUL of equipment, but in no case can it be less than 5 years.
- Computation of the RUL is based on when the equipment is delivered to the beneficiary, not the age of the equipment.
- Replacement due to wear is not covered during the RUL of the equipment.
- During the RUL, Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically necessary equipment owned by the beneficiary.
Not Covered
The items listed below are not covered for replacement.
- Charges for the replacement of oxygen equipment
- Items that require frequent and substantial servicing
- Inexpensive or routinely purchased items which are being rented
Replacement of Prosthetics - There are special rules for the replacement of artificial arms, lower limbs, and eyes. You can find more information on the Replacement webpage.
Is the Item Same or Similar?
Prior to replacing an item, and to gain the necessary information required for determining whether same or similar is affected, these questions should be considered:
- Has there been a change in the beneficiary's medical condition that supports the need for a same or similar type of item?
- Has the original item been lost, stolen, or irreparably damaged?
- Answering these questions will help determine whether an Advance Beneficiary Notice of Noncoverage (ABN) should be obtained
- Has the beneficiary had a same or similar item?
- If he/she has not had a same or similar item, bill claim without obtaining an ABN (no ABN necessary)
- If he/she has had a same or similar item, determine if item has reached its RUL
- If RUL reached, bill claim without ABN (no ABN necessary)
- If item has not reached RUL, obtain an ABN and bill claim with applicable modifier
Verification options include:
- Ask beneficiary
- Check via Noridian Interactive Voice Response (IVR)
- Access such information within Noridian Medicare Portal (NMP)
If there is any reason to believe that a beneficiary may have obtained a same or similar item outside of Jurisdiction A, check with the other jurisdictions (B, C, and D) as well.
- Same or Similar: How to Avoid Denial
- Same or Similar Denials
- Same or Similar and Advance Beneficiary Notice of Noncoverage (ABN) Documentation
- Reasonable Useful Lifetime Clarification
- Reasonable Useful Lifetime and Duplicate Items - Billing Reminder
Same or Similar Chart
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.
Item | Item Type | Same HCPCS Category | Similar HCPCS Category |
---|---|---|---|
AFO/KAFO | O&P | 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 | |
Bed Side Rails | DME | E0305, E0310 | Hospital Beds with Rails E0250, E0251, E0328, E0255, E0256, E0260, E0261, E0329, E0265, E0266, E0301, E0302, E0303, E0304 |
Blood Glucose Monitors | DME | E0607, E2100, E2101, E2104 | |
Canes and Crutches | DME | E0100, E0105, E0110, E0111, E0112, E0113, E0114, E0116 | |
Commodes | DME | E0163, E0164, E0165, E0166, E0168, E0169, E0170, E0171 | |
Continuous Glucose Monitors and Blood Glucose Monitors | DME | E2103 | E0607, E2100, E2101, E2102, E2104 |
Continuous Glucose Monitors | DME | E2102 | E2103 |
External Breast Prosthesis | O&P | L8015, L8020, L8030, L8031, L8032, L8035, L8039 | |
External Infusion Pumps | DME | E0779, E0780, E0781, E0791 | |
Functional Electrical Stimulator | DME | E0764, E0770 | E0720, E0730, A4595 |
Heat Lamps | DME | E0200, E0205 | |
Heat Pads | DME | E0210, E0215, E0217, E0220, E0221, E0225, E0236, E0238, E0239 | |
High Frequency Chest Wall Oscillation Devices | DME | E0483 | E0480, E0482 |
Hospital Beds | DME | E0250, E0251, E0255, E0256, E0260, E0261, E0265, E0266, E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297, E0301, E0302, E0303, E0304, E0328, E0329 | |
Humidifiers Note: When used with a positive airway pressure (PAP) device |
DME | E0561, E0562 | |
Knee Orthoses | O&P | L1810, L1812, L1820, L1821, L1830, L1831, L1832, L1833, L1834, L1836, L1840, L1843, L1844, L1845, L1846, L1847, L1848, L1850, L1851, L1852, L1860 | |
Manual Wheelchairs | DME | E1031, E1037, E1038, E1039, E1161, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1239, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0009 | Canes and Crutches E0100, E0105, E0110, E0111, E0112, E0113, E0114, E0116 Walkers E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149 |
Mechanical In-exsufflation Devices | DME | E0482 | E0480, E0483 |
Nebulizers and Compressors | DME | E0565, E0570, E0571, E0572, E0574, E0575, E0580, E0585 | |
NEMS | DME | A4595 | E0720, E0730, E0764, E0770 |
Oxygen Contents (Portable) | DME | E0443, E0444 | |
Oxygen Contents (Stationary) | DME | E0441, E0442 | |
Oxygen, Portable Equipment | DME | E0430, E0431, E0433, E0434, E0435, E1392, K0738 | |
Oxygen, Stationary Equipment | DME | E0424, E0425, E0439, E0440, E1353, E1390, E1391, E1405, E1406 | |
Parenteral Pumps | DME | B9004, B9006 | |
Patient Lifts | DME | E0630, E0635, E0636, E0639, E0640 | |
Patient Lifts | DME | E1035, E1036 | Canes and Crutches E0100, E0105, E0110, E0111, E0112, E0113, E0114, E0116, E0117, E0118 Walkers E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149 Patient Lifts E0630, E0635, E0636, E0639, E0640 |
Percussor | DME | E0480 | E0482, E0483 |
Pneumatic and Non-Pneumatic Compressor Appliances - Arm | DME | E0655, E0665, E0668, E0672 | E0682, K1025 |
Pneumatic and Non-Pneumatic Compressor Appliances-Leg | DME | E0660, E0666, E0667, E0669, E0671, E0673 | E0678, E0679, K1032, K1033 |
Pneumatic and Non-Pneumatic Compressor | DME | E0650, E0651, E0652 | E0680, E0681, K1024, K1031 |
Pneumatic Compressors Trunk Appliances | DME | E0656, E0670 | |
Positive Airway Pressure (PAP) Device | DME | E0601 | E0450, E0454, E0460, E0461, E0463, E0464, E0465, E0466, E0470, E0471, E0472 |
Power Wheelchairs | DME | E1035, E1036, E1230, K0013, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891, K0898 | Manual Wheelchairs E1031, E1037, E1038, E1039, E1161, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1239, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0009 Walkers E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149 Canes and Crutches E0100, E0105, E0110, E0111, E0112, E0113, E0114, E0116, E0117, E0118 |
Pressure Reducing Support Surfaces | DME | E0181, E0182, E0184, E0185, E0186, E0187, E0188, E0189, E0193, E0194, E0196, E0197, E0198, E0199, E0277, E0371, E0372, E0373 | |
Respiratory Assist Devices | DME | E0450, E0454, E0460, E0461, E0463, E0464, E0465, E0466, E0470, E0471, E0472 | E0601 |
Seat Lift Mechanisms | DME | E0172, E0627, E0629 | |
Speech Generating Devices | DME | E2500, E2502, E2504, E2506, E2508, E2510, E2511 | |
Spinal Orthoses - Lumbar Sacral Orthoses | O&P | L0450, L0452, L0454, L0455, L0456, L0457, L0458, L0460, L0462, L0464, L0466, L0467, L0468, L0469, L0470, L0472, L0480, L0482, L0484, L0486, L0488, L0490, L0491, L0492, L0621, L0622, L0623, L0624, L0625, L0626, L0627, L0628, L0629, L0630, L0631, L0632, L0633, L0634, L0635, L0636, L0637, L0638, L0639, L0640, L0641, L0642, L0643, L0648, L0649, L0650, L0651 | |
Stimulators | DME | E0747, E0760 | |
Therapeutic Shoes for Persons with Diabetes | O&P | A5500, A5501 | |
Traction Frames | DME | E0840, E0850, E0855, E0856, E0860, E0947, E0849 | |
Transcutaneous, Electrical Nerve Stimulators (TENS) | DME | E0720, E0730 | E0764, E0770, A4595 |
Trapeze Bars | DME | E0910, E0911, E0912, E0940 | |
Ventilators | DME | E0465, E0466, E0467 | |
Walkers | DME | E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149 | Canes and Crutches E0100, E0105, E0110, E0111, E0112, E0113, E0114, E0116, E0117, E0118 |
Wheelchair Back Cushions | DME | E2611, E2612, E2613, E2614, E2615, E2616, E2617, E2620, E2621 | |
Wheelchair Seat Cushions | DME | E2601, E2602, E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2610, E2622, E2623, E2624, E2625, K0734, K0735, K0736, K0737 |