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
