APMA News - March/April 2019 - 38

Reimbursement
By the APMA Health Policy and Practice Committee

New Enforcement of 'Same or Similar'
DME MAC Policy: How to Protect Yourself and
Ensure Your Patients Get the Care They Need
APMA has recently been made aware that DME MACs are
What to Do
now strictly enforcing a long-existing "same or similar" policy
(https://med.noridianmedicare.com/web/jadme/topics/
Providers can easily discover whether their patient has resame-or-similar/ss-and-abns). This enforcement change means
ceived a device within the past five years by enrolling in their
that suppliers are more frequently receiving denials for DME,
respective DME MAC Jurisdiction's provider portal. Informaindicated on explanations of benefits with reason code M3.
tion on enrolling in the provider portals is available on each
Medicare policy permits AFOs to be dispensed only once,
DME MAC home page.
per limb, every five years. The "same or similar" policy states
APMA urges our members not to use the NMBI (National
that a beneficiary cannot get another AFO device for the same
Medicare Beneficiary Identifier) and to continue to use the
limb within this period unless the AFO is lost, stolen, or irreppatient's Social Security-linked number as there are cases in
arably damaged, or the pawhich the provider portal eitient has a new diagnosis, rether will not recognize the
The "same or similar" policy states
sulting in the need for a new
NMBI or cannot properly
type of device. Further comperform a "same or similar"
that a beneficiary cannot get another
plicating the issue, the rule is
inquiry. This issue has been
AFO device for the same limb within
not provider-specific, meanbrought to the attention of
ing that if a patient received
this period unless the AFO is lost, stolen, CMS contractors. Once this
an AFO from another providissue is resolved, APMA will
or irreparably damaged, or the patient
er or supplier within the past
notify members.
five years that was billed to
Once providers enroll in
has a new diagnosis, resulting in the
Medicare, the claim for a
their DME MAC carrier's porneed for a new type of device.
"same or similar" device may
tal, they will be able to see
be denied. For example, a paany DME their patient may
tient who received a CAM Boot (L4386) in 2017 for a stress
have been dispensed in the past five years including the date,
fracture on the left foot from one provider would likely be reHCPCS codes, and name of the supplier who provided the prejected for a Custom Fabricated Hinged AFO (L1970) should he
vious device.
or she require one for a diagnosis of posterior tibial tendinosis
APMA suggests that providers confirm their patient's legal
of the left foot in 2019 from a new doctor.
address history. This information will minimize any possibilMembers can find policy details by visiting their region's
ity that "same or similar" services were provided previously in
DME MAC website.
a different DME MAC Jurisdiction. The Noridian Provider
Portal will only provide "same or similar" information regarding services provided in Regions A and D, while MyCGS will
only provide "same or similar" information for services proAFOs considered to be within the "same or similar"
vided in Regions B and C.
category include both custom-fabricated and off-theAdditionally, providers should save any information reshelf devices, including:
ceived on the provider portal and should be sure their chart
documentation includes the above information. If a provider
L1900, L1902, L1904, L1906, L1907, L1910,
L1920, L1930, L1932, L1940, L1945, L1950,
is dispensing another AFO for the same side within five years,
L1951, L1960, L1970, L1971, L1980, L1990,
he or she should be sure to document that a new device is reL2000, L2005, L2010, L2020, L2030, L2034,
quired for one of the several reasons stipulated in the LCD.
L2035, L2036, L2037, L2038, L2106, L2108,
These reasons include, but are not limited to:
L2112, L2114, L2116, L2126, L2128, L2132,
device was lost, stolen, or irreparably damaged (due to a
L2134, L2136, L4350, L4360, L4361, L4370,
one-time event);
L4386, L4387, L4396, L4397, L4398, L4631.
different diagnosis;
change in anatomy (e.g., amputation, significant weight

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38 APMA News March/April 2019
https://med.noridianmedicare.com/web/jddme/topics/same-or-similar/ss-and-abns https://med.noridianmedicare.com/web/jddme/topics/same-or-similar/ss-and-abns
APMA News - March/April 2019

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