van Halem Group

Post

By Donna Youngblood RN, BSN, CPC

Same or similar denials occur when claims information is checked against the patient’s CMN history. This will indicate when equipment is “same or similar” to that piece of equipment being billed on the claim.

These types of denials can be avoided early on when providing DME equipment to patients. The essential step in preventing this type of denial is by having a thorough intake process. Suppliers are encouraged to use an intake form to assure all necessary information is obtained prior to dispensing DME items. Such information may include:

Patient’s correct Medicare Beneficiary Identifier (MBI);
Whether the patient has other insurance
Patient's current and previous address to check against MAC Jurisdictions/states
If the patient currently has or had this type of equipment or similar equipment in the past;
When the item(s) were received and if the item(s) have been returned;

It is the supplier's responsibility to check the Supplier Interactive Voice Response (IVR) system or portal to determine if same or similar HCPCS are on file for a patient within the previous five years or specific reasonable useful lifetime (RUL) for an item.

When using the web portals, be sure that you are checking both individual and HCPCS code ranges. The MAC contractors have slight variations in their search criteria. For example:

Use an '*' to search all codes in a range on the CGS Portal (i.e. E* will return all E codes provided)
Search HCPCS code ranges on the Noridian Portal (i.e. B0000 - B9999)

If no same and similar equipment is found, save a print out of the results to the patient file to document your due diligence.

In the event that same or similar is suspected, a supplier must provide a properly executed Advance beneficiary Notice of Noncoverage (ABN) for each item likely to be denied as not medically necessary if justification for replacement of the item cannot be documented.