Same or Similar – DMERC denials

The denials for same or similar are numerous and difficult to work if we don’t have all the information upfront. There is a special RA modifier that is needed in addition to the normal side and KX modifiers in some cases. A GA is needed instead of the KX in other cases. Billing needs to know that the patient had a similar/same within the last 5 years before we bill so we can get the info needed to submit the correct modifiers the first time. But understand this simple fact – if a patient has had an item from the chart below within 5 years of getting another item from that chart (for the same side) the new item will deny. Always. Then we have to work the denial by sending reconsideration/redetermination with all the required documentation and ABN to see if that denial can be overturned. Required documents will vary depending on the reason an item is being given out a second time within 5 years.

These codes are considered the same thing:

L1900, L1902, L1904, L1906, L1907, L1910, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1980, L1990, L2000, L2005, L2010, L2020, L2030, L2034, L2035, L2036, L2037, L2038, L2106, L2108, L2112, L2114, L2116, L2126, L2128, L2132, L2134, L2136, L4350, L4360, L4361, L4370, L4386, L4387, L4396, L4397, L4398, L4631

In an effort to help us all better understand the same or similar process and the correct billing of these items, I am suggesting we all watch this 12-minute webinar. Hopefully, if we are all on the same page, we can get more payments on these items and supply fewer items that aren’t payable.

https://med.noridianmedicare.com/web/jadme/education/dme-on-demand

Go to section Coding Guidelines and then the Same or Similar section. Select the Orthotics – Same or Similar – 12 minutes webinar and enjoy the exciting video.

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