Same and Similar Item Due to Change in Medical Condition

Written by Guest Blogger, Michelle Wullstein

Replacement criteria for orthotics under the Medicare program can be complicated, so knowing when to administer an Advance Beneficiary Notice of Non-coverage (ABN) and how to properly bill the claim can be tricky. If it has been identified that the item being dispensed could potentially deny due to a same/similar item in the patient’s history (up to five years depending on the item), consider this before dispensing the item:

What are ALL the reasons you are expecting a Medicare denial? Is this just a same/similar issue or are there other issues that need to be addressed?

Has the beneficiary experienced a change in condition since the previous item was dispensed? If yes, you’ll want to make sure the physician’s office notes detail the change in condition and why the previous item no longer meets the patient’s medical needs. This information should be corroborated by the orthotist’s notes.

Make sure the ABN is valid. Once you have determined that an ABN is appropriate, make sure it is filled out in its entirety, it is written using language/terms the beneficiary can understand (avoid industry jargon or acronyms), and you have included ALL reasons why the claim is expected to deny (see item 1). Failure to identify all applicable reasons could result in the ABN being deemed “invalid.”  

Submit the claim properly so it can be appealed appropriately. When a valid ABN is on file, the claim should be billed with the GA modifier. Suppliers can almost always expect a denial when billing the GA modifier. If documentation is available to support a change in condition, the documentation submitted in the first level of appeal should support the DME MAC overturning the original denial. In this situation, the DME MAC redetermination examiner will remove the GA modifier and add the KX modifier to the claim; it is not necessary to ask for this to be done. In fact, if a supplier requests the GA modifier be removed in the appeal and the documentation does not support the change in condition, the denial may be upheld as a contractual obligation, not patient responsibility. So always let the examiner replace the GA modifier with the KX modifier if they deem the documentation is sufficient to support replacement.

Michelle’s Medicare experience began in 2006 at Noridian Healthcare Solutions, as a Medicare Contractor, working under the Part B Physician’s and DME Medicare contracts. With her background, Michelle is helpful to orthotic and prosthetic suppliers as they navigate compliance and communication with their referral sources. She understands that orthotic and prosthetic suppliers face a unique set of challenges compared to traditional DME suppliers and finds joy in helping them overcome these challenges and thrive in today’s market.

For more information on ABN Usage and Proper Billing or any other Same and Similar questions, please reach out to Michelle Wullstein or Lesleigh Sisson, CFom at O&P Insight. If you would like to setup a continued education webinar with O&P Insight, please contact your Cascade Account Manager today!