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Proactive Preparation for Same or Similar
By: Stacy Toner, CBCS
When a boxer prepares for a fight, he/she starts months in advance. Working out, training, studying the opponent so when fight night comes, he/she is strong and ready. If you knew a fight was coming, wouldn’t you do everything possible to prepare yourself?
Industry-wide we are seeing an alarming increase of claims being audited and denied for same or similar. We are seeing that the two main reasons for same or similar denials being upheld are: "not enough documentation necessitating a replacement within the reasonable useful lifetime" and "invalid ABN on file".
In this article we will review denial scenarios and our recommendations on creating a proactive process for preparing for and fighting same or similar denials when they come through.
Background & Breakdown
In CMS' policy there are two important definitions to point out. First, the policy states equipment may be replaced in the event of loss or irreparable damage and the term "irreparable damage" refers to a specific accident or natural disaster. The second important point is the definition of the term "irreparable wear" which is stated to refer to the "deterioration sustained from day-to-day usage over time and a specific event cannot be identified". Not only does the policy distinguish between irreparable wear and irreparable damage, it denotes that irreparable damage is covered during the RUL and irreparable wear is not.
So, what does this mean for you when providing a same or similar device within the Reasonable Useful Lifetime Rule? The solution is in your preparation for the inevitable denial and your documentation.
When a same or similar item is delivered within the RUL, Medicare will only reimburse the replacement under certain circumstances. Those circumstances are loss/theft, irreparable damage and change in condition.
First, we need to explore how to justify for each covered reason. Below are some examples of justifying loss/theft, irreparable damage and change in condition.
Loss: Today we are providing a replacement to the L1970 the patient was provided on May 14, 2017. The patient reports being on vacation in Los Angeles and accidentally leaving the brace in the hotel room. Upon returning home to Portsmouth, NH the loss was discovered and all attempts to locate the brace have failed. The hotel reports not seeing a brace upon cleaning the room. The patient requires a replacement to facilitate continued safe ambulation. The patient currently meets all requirements for ambulation, weakness or deformity and potential to benefit functionally from the prescribed brace.
Irreparable Damage: On May 12, 2016 the patient was provided with a L1932 which was functioning well for the patient and providing proper support. On April 24, 2019 the patient stepped off a high curb and landed awkwardly. The associated force through the brace caused severe delamination of the carbon strut resulting in catastrophic damage. The damage to the brace resulted in the brace no longer meeting the medical or functional need of the patient. The damage cannot be repaired, and the brace requires immediate replacement to facilitate continued safe ambulation. The patient currently meets all requirements for ambulation, weakness or deformity and potential to benefit functionally from the prescribed brace.
Change in Condition: The brace is replacing the same or similar brace identified as L1902, provided on May 14, 2016. That brace was prescribed to manage a sprained ankle associated with a fall and was not expected to be long term. The patient’s condition has now changed as she is now diagnosed with ALS. The ankle brace from 2016 does not meet her current medical needs. She now requires a definitive AFO to manage her progressing weakness. Patient currently meets LCD requirements for ambulation, weakness or deformity and potential to benefit functionally from the brace prescribed.
Knowing the policy and how to effectively document a justification for replacement will be one of the two best lines of defense against same or similar denials. However, your very first line of defense against any denial is your verification of benefits procedures.
Medicare holds the supplier responsible for checking same or similar for equipment being delivered; This can be done on the DME MAC portal or on the interactive voice response (IVR) system. It is important to note that when checking for same or similar through either the portal or IVR, it is recommended for providers to always check the range of L0000 through L9999 to ensure all possible deliveries in the last five years are pulled out of the system. Some commercial payers allow you to check same or similar with their customer representatives.
CBS recommends always calling to speak with someone when verifying benefits to check same or similar and get the most accurate verification possible. This practice allows you to document who you spoke with, as well as obtaining a reference number for the call so, if you get a same or similar denial you can reference the information provided to you during the verification of benefits.
In the case of checking same or similar on the DME MAC portal it is recommended that you print out a screenshot of the check to help build your case against potential denials. We were recently informed by a Medicare customer service representative that with the recent transition from HICN to MBI numbers, the patient's full records are not showing up on the portal when searching the MBI; Therefore, same or similar devices were not coming up. A print out will show that you did you due diligence and were provided with certain information.
The second most common denial reason is for the Advance Beneficiary Notice of Noncoverage (ABN) issued to the beneficiary being invalid. ABNs should be issued to a beneficiary prior to the service being provided, giving the patient ample time to make an educated decision about receiving the equipment. The provider should fill out the information about the equipment and potential denial reason in common terminology the patient will understand and explain to the patient what the notice means. The beneficiary needs to be the individual who selects one of the three options on the ABN:
1.) Receive the item and have it billed to Medicare
2.) Receive the item and pay for it out of pocket, provider does not bill Medicare
3.) Do not receive the item
More than anything we are seeing ABNs denied for the expected denial reason being invalid. On September 19, 2018 CMS released a bulletin on the DME MAC List Serves explaining what type of reasons are valid.
Be sure to complete a valid ABN when delivering a same or similar device so that your patient is aware of the possible denial and you have the appropriate documentation in case of an appeal.
Same or similar is a topic at the front of our brains in O&P right now and it is something that should always be. Incorporate proactive preparation for the denial into your procedures from the second your patient walks through the door. From a questionnaire that includes bracing history to verification and documentation practices, you can build an argument for replacement before a denial ever happens. When you know the fight is coming, study your opponent and train for the fight.
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