Here’s Why Same or Similar Checks for Braces Don’t Work

Medicare suppliers are often frustrated with frequent same or similar denials for brace claims. In part, physicians commonly prescribe new braces to patients recovering from surgery or other injuries without first asking about braces the patient may already have at home. But while the nature of the ordering process may increase the risk, there are two supplier intake deficiencies primarily to blame for these persistent denials:

1. Skipping same or similar checks.
2. Checking for history in the wrong place.

Of course, no process is effective if skipped altogether, so intake personnel must complete same or similar checks before every setup or delivery. Nonetheless, a common mistake can foil even diligent brace suppliers and lead to incorrect results and denied claims …using the incorrect search method.

DME MAC portals provide two methods for same or similar searches:

1. CMN data searches.
2. Claim data searches.

Traditional same or similar searches query the electronic CMN documents Medicare creates to track monthly payments and one-time purchase transactions for traditional DME billed with E and K codes. Medicare does not, however, create CMN documents for the L codes for braces, so suppliers need to search patient claim data for evidence of a paid claim for L codes.

Suppliers often use the wrong search method because the DME MAC portals do not make a clear distinction between the two available options. Individuals using the incorrect method are often none the wiser because choosing incorrectly produces no error. The system simply returns no results, leaving the user with a false sense of security.

Here’s how suppliers can get to the right source to check claim data for evidence of a past brace.
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Jurisdictions B and C (MyCGS):

• Go to the Claim History menu.
• Go to the Claim Preparation tab.
• Select the second tab for Claim History.
• Enter “L” instead of a specific HCPCS.

Jurisdictions A and D (Noridian Medicare Portal):

• Click the Same or Similar menu on the home page.
• Select option 2 (search for all paid dates of service for a range of HCPCS).
• Enter “L0001” to “L9999.”

By following these steps, the system will return every paid brace from the last five years.

What should suppliers do when they find a brace in history?

Ask the patient what happened to their last brace. Depending on the answer, suppliers have three options:

1. Provide a new brace if Medicare covers an early replacement.
2. Execute an ABN to transfer payment responsibility to the patient.
3. Refuse the order.

For the first scenario, Medicare will pay for an early replacement if the supplier can produce documentation supporting:

• The beneficiary lost or damaged the previous brace.
• A change in condition renders the previous brace inappropriate.

For the second scenario, assuming Medicare will not cover an early replacement, the supplier can execute an ABN to inform the patient Medicare will probably deny the current claim due to the previous brace. Once the patient signs the ABN, suppliers can collect payment at the time of delivery.

Using the correct eligibility tools is a simple way to eliminate many of the denials that clog reports, consume billing resources, and disrupt revenue.

SOURCE LINKS
https://cgsmedicare.com/jc/pubs/news/2020/08/cope18619.html
https://med.noridianmedicare.com/web/jadme/topics/same-or-similar 
https://med.noridianmedicare.com/web/portalguide/inquiry-guide/same-or-similar
https://cgsmedicare.com/jc/pubs/news/2020/01/cope15520.html