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:
DME MAC portals provide two methods for same or similar searches:
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.
Jurisdictions B and C (MyCGS):
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:
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
- Skipping same or similar checks.
- Checking for history in the wrong place.
DME MAC portals provide two methods for same or similar searches:
- CMN data searches.
- Claim data searches.
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.
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.
- 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.”
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:
- Provide a new brace if Medicare covers an early replacement.
- Execute an ABN to transfer payment responsibility to the patient.
- Refuse the order.
- The beneficiary lost or damaged the previous brace.
- A change in condition renders the previous brace inappropriate.
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