Same or Similar

What You Need to Know

Medicare has specific rules and guidelines for providing items that are identical or similar to items previously provided to the same patient. These guidelines are based on "same or similar" devices delivered within the Reasonable and Useful Lifetime of the original device. Typically, any brace that is worn on the same part of the body is considered "similar," even if their function is different. For example, a CAM boot is considered "similar" to a custom AFO. Noridian has a Same or Similar Chart, which list out all the HCPCS codes in a given category (e.g., AFO/KAFO, knee orthoses, spinal orthoses, etc.) that are considered "similar" to each other. CGS provides the same information using their Same/Similar Code Lookup tool. 

The RUL for DME, as defined by the Medicare Benefit Policy Manual, is no less than 5 years unless a different RUL is established by program instructions (i.e., Policy Articles). It is important to note that prosthetic devices are not strictly bound by RULs and have different replacement guidelines altogether. For orthotic/bracing devices, the following RULs are established by the CMS guidelines and their respective Policy Articles:

• 1 Year: L1810, L1812, L1820, and L1830
• 2 Years: L1831, L1832, L1833, and L1850
• 3 Years: L1836, L1843, L1845, L1851, L1852, and all custom knee orthoses
• 5 Years: All other orthoses, including AFOs/KAFOs and spinal

Medicare will provide coverage for a same or similar brace provided within the RUL if there is a change in the patient's medical condition that necessitates the need for a new brace or the original brace was lost, stollen, or irreparably damaged. Damage of a device can be traced to a specific event, unlike wear, which is deterioration sustained from day-to-day usage over time. Irreparable wear is not covered by Medicare within the RUL.

What this Means for You

Before providing a DMEPOS item to a Medicare beneficiary, it is important to verify whether or not they received a same or similar device in the past. This information can be verified on the Noridian Medicare Portal for Jurisdictions A and D (NMP User Guidance) and on the myCGS portal for Jurisdictions B and C (myCGS User Manual). If you do not have access to the portal or prefer to verify over the phone, you can also verify this information using the Interactive Voice Response system. The online portal and IVR verifications are unique for each jurisdiction and do not contain claim information from the other jurisdictions. Because of this, you may receive an unexpected denial if your patient received a same or similar device that was billed to a different jurisdiction. You should always confirm with your patient whether or not they received a same or similar device within the past five years, but if they do not remember, the only way to be completely accurate is to verify each jurisdiction separately.

If you determine that your patient received a same or similar device within the RUL of that device, it is important to clearly document the reason for replacement. For devices that were lost, stolen, or have irreparable damage, you should explain the condition of the device in your notes and obtain relevant documentation from the patient (i.e., a written statement, police report, fire report, insurance claim, etc.). For patients who had a change in their medical condition, your documentation should not only explain this change, but also discuss why the previous device is no longer appropriate and justify medical necessity for the newly prescribed device. In both cases, the referring physician needs to provide a new order to justify continued medical necessity for the device. If you are unable to obtain proper documentation, then you should have the patient sign an ABN and specify in "Blank E" that the patient received a same or similar device within the RUL.

Once you obtain all documentation, use the following modifiers to bill for a same or similar device:

• RA: Lost, stolen, or irreparable damage (include narrative with reason for replacement)
• KX: Change in medical condition with appropriate documentation
• GA: ABN on file and do not expect Medicare to cover replacement

If your claim is denied by Medicare for same or similar, you will receive a remittance advice from the DME MAC with remark code M3 (equipment is the same or similar to equipment already being used). For claims that meet the above coverage criteria, submit a redetermination and include all documentation to justify coverage for replacement. If an ABN was obtained, be sure to include the ABN with your redetermination.

You can find more information on same or similar denials on the Noridian and CGS websites.