10/19/2020
Billing for L4361 (Pt with Fracture)-Same and Similar Scenario
we have a patient who presented with a fracture today, and we were going to dispense a new fracture walker (code L4361) on her left foot, however, she was dispensed the same code ON 9-14-17 for a dx of plantar fasciitis same foot. She was also dispensed L1902 on 11-11-19 same foot. According to CMS guidelines, dated 9-10-20 0167-Excessive units, the code will be denied for dos within reasonable useful lifetime from prev paid identical code for same beneficiary. Is there a modifier we could use to get this paid or another way to bill, as this is completely different diagnosis and patient no longer has the old fracture walker. We cannot just let her walk with a fracture unassisted. Please advise.
The only modifier applicable here would be RA - Replacement of a DME item, due to loss, irreparable damage or when item has been stolen--however, it is inappropriate here since the L1902 was not lost or damaged and this claim will deny with code 151 for frequency/same and similar at which time you can do a redetermination. (See below for appeals process)
It is critical to document the medical necessity for a new fracture walker. The documentation would need to be as thorough as possible, and would need to include details on how the patient no longer has the prior fracture walker that was dispensed back in 2017 and how the AFO from 2019 is not suitable for the patients current condition. State why this new fracture walker is necessary since this is a completely different medical condition.
See link below for our Same and Similar News Alert posted on the CPR portal:
https://www.nyspma.org/aws/NYSPMA/asset_manager/get_file/305884?ver=113
Same or Similar Denials for Orthoses and the Appeals Process
Change In Medical Condition
If a claim for an orthosis is denied as same or similar, the supplier may submit a redetermination. If the replacement orthosis is provided due to a change in medical condition, the supplier should submit the following at a minimum (with the redetermination form):
- Standard written order (SWO);
- Proof of delivery; and
- Medical record documentation to substantiate a change of medical/physiological condition.
The medical records should demonstrate the beneficiary’s change in medical/physiological condition necessitating the need for the new orthosis. A focused history and examination of the impacted body part is critical to establishing medical necessity. The medical record should include (but is not limited to):
- the beneficiary’s diagnosis
- prognosis
- duration of condition
- functional limitations
- clinical course
- past experience with related items
- reasons why previous orthotic devices are not functional nor appropriate for the current condition.
The orthotist (supplier) records are a part of the medical record, and are considered in the context of documentation made by the treating practitioner and other healthcare practitioners, to provide additional details to demonstrate the item is reasonable and necessary. The orthotist’s notes are expected to corroborate and provide details consistent with the practitioner’s records. Medical necessity and subsequent payment will not be provided solely based on the orthotist’s documentation. Supplier prepared statements and practitioner attestations, by themselves, do not provide sufficient documentation of medical necessity; even if signed by the ordering practitioner. These documents are not considered part of the medical record.
Lost, Stolen, or Irreparably Damaged
When providing a replacement orthosis which is lost, stolen or irreparably damaged (irreparable damage refers to a specific incident or to a natural disaster (e.g., fire, flood)), and the claim is denied due to same or similar equipment on file, a redetermination may be submitted, and must include documentation of the loss or irreparable damage, as well as a SWO to reaffirm the medical necessity of the item. These redetermination instructions are the same as noted for a change in medical/physiological condition.
Coverage
Certain types of orthoses have specific coverage requirements and these coverage requirements must be met to receive payment. These coverage details are available in the Ankle-Foot/Knee-Ankle-Foot Orthosis, Knee Orthoses, and Spinal Orthoses: TLSO and LSO Local Coverage Determinations and related Policy Articles found on the Medicare Coverage Database (L33686 , A52457 ; L33318 , A52465 ; and L33790 , A52500 , respectively); additional documentation requirements are addressed in the Standard Documentation Requirements article A55426.
Information regarding the appeal process including timeframes, addresses, fax numbers, submission forms, and checklists is located on each DME MAC’s website.
Jurisdiction A: https://med.noridianmedicare.com/web/jadme/claims-appeals
Jurisdiction B: https://www.cgsmedicare.com/jb/claims/appeals/index.html
Jurisdiction C: https://www.cgsmedicare.com/jc/claims/appeals/index.html
Jurisdiction D: https://med.noridianmedicare.com/web/jddme/claims-appeals