06/26/2020

DME-Same and Similar Policy

hi. I gave a patient a gauntlet L1902 for achilles tendon pain. after mri showed partial interstitial tear, I want to dispense a cam boot. pt has medicare in brooklyn ny. can i submit a cam boot for billing since i already billed for gauntlet or there is a 5 year period?

Based on the same/similar policy from Noridian Medicare Services, the jurisdiction A DME MAC, an ankle gauntlet and cam boot are considered within the same category of prosthetics and orthotics. Since they are within the same category by the DME MAC, only one of the two items will be payable by Medicare. If a claim has already been processed for the ankle gauntlet, the claim for the cam boot will deny for frequency of service.

The chart note for the dispensing of the cam walker must state that the patient has previously received a gauntlet for "x" medical condition.  It must also state that the previously dispensed item is inappropriate for the treatment of the current condition and a cam walker is more appropriate because of "xxx rationale".  Once the charge for the cam walker denies, you will need to file a redetermination with supporting documentation (chart note).

***We highly recommend that you check with Noridian to see if the patient had anything else dispensed within the last 5 years--if so you will need to mention that in the note as well and explain why that product is not the best course of treatment for the current condition.