Working Down Denials

M3 Same or similar equipment

The Jurisdiction D DME MAC (Noridian Administrative Services) says it is seeing many claims for wheelchairs and power mobility devices were it has been

The Jurisdiction D DME MAC (Noridian Administrative Services)
says it is seeing “many claims for wheelchairs and power
mobility devices were it has been less than five years since the
beneficiary received a similar piece of equipment.” The
reason for the increase in these denials is that there is no
comment on the claim to explain why a new piece of equipment is
being billed. This leads to the claim being denied as “same
and similar” due to existing equipment being on file. These
denied claims have remark code “M3” on the remittance
advice. The wording for M3 is “Equipment is the same or
similar to equipment already being used.”

It is important when billing for a purchase or rental of a DME
item when it has been less than five years since the beneficiary
received a similar piece of equipment to include the pick-up date
and the reason for the pick-up of the previous equipment in the
claim narrative (NTE field).

For patients who still own their equipment, there would not be a
pick up slip listed on the initial claim for the new equipment.
State that the patient's condition has deteriorated and that the
previous owned equipment can no longer meet the patient's current
medical needs. This information would be placed in the NTE field.
Without this information, the current claim will be denied as
“same and similar” due to existing equipment being on
file.

For example, if a beneficiary is renting a K0001 standard
wheelchair and his/her condition worsens to the point that only a
different wheelchair, such as a K0823 power chair, will meet his or
her medical need, coverage will be allowed for the K0823, and the
K0001 will be denied as same or similar equipment.

According to NAS, the statutory basis for denial of such
“same and similar” claims is medical necessity;
therefore, the limitation on liability provision under Section 1879
of the Social Security Act applies. If an ABN has not been
obtained, stating there is similar equipment on file, the supplier
will be liable for this denial. If an ABN is obtained and the
“GA” modifier reported on the claim, the beneficiary
will be liable.

A pick-up slip should be on file showing that the previous
equipment is no longer being used by the beneficiary. A pick-up
slip is written confirmation, provided by a supplier, that the
supplier has removed an item of DME from the beneficiary's
home.

Sarah Hanna is a reimbursement consultant and vice president of
ECS Billing & Consulting, Tiffin, Ohio, and specializes in
proper billing protocols, Medicare coverage guidelines and billing
office procedures. She can be contacted at 419/448-5332 or sarahhanna@bright.net.

Across the four Medicare jurisdictions in the second quarter
of 2008, claim denials for K0001 (standard wheelchair) averaged
24.1%, and denials for K0823 (PWC, Group 2 standard captain's
chair) averaged 21.3%. Based on analysis of 5,617,383 claims
adjudicated by the DME MACs and processed for RemitDATA customers
from April-June, 2008. Source: RemitDATA, 866/885-2974,

www.remitdata.com



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