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.

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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