Depending upon several defined factors, Medicare may deem a DMEPOS product non-covered due to the Medicare Beneficiary previously receiving a Same or Similar device. MotionMD® features an optional Same or Similar check that can be enabled for all straight Medicare patients for DMEPOS products with ‘E’ or ‘L’ HCPCS code. Payors other than straight Medicare are excluded from the MotionMD® Same or Similar check.
The MotionMD Same or Similar check is designed to verify the HCPCS code and laterality (RT/LT) within the applicable Reasonable Useful Lifetime (RUL) of products being dispensed to patients. If the HCPCS does not have a ‘similar’ product grouping per CMS, MotionMD Same or Similar will verify against the same HCPCS and laterality only, providing a PASS/FAIL result. If a HCPCS has a ‘similar’ product grouping, MotionMD Same or Similar will verify against all HCPCS in the similar grouping and provide a PASS/FAIL result.
During PA creation, the ‘Check Same or Similar’ button will appear in the Payment Method section if Medicare is selected, and if the HCPCS code of the product is an E code or an L code. The button will not appear for A codes, a Payment Method other than Medicare, or if a product has not been added. Note: The 2-character state code is needed within the Customer Section on the Payment Method.
Same HCPCS Scenario:
In the following scenario a PA was created for a patient, an L1970 product was added for the Right side along with a Payment Method of Medicare.
To start the Same or Similar verification, click the Check Same or Similar button within the Payment Method section
Users will see a notice within the Same or Similar section ‘Awaiting Same or Similar results’
Note: The results can take up to 2 minutes to be received, though they typically return more quickly. While the review is underway, Users can continue to complete the PA or navigate away from the PA and return later to view the results
A message will show the review is complete and results are available along with most recent date and time of results. Click the See Results button to view response
A modal will open that includes all of the L or E codes (depending on the first product listed on PA*) the patient has been dispensed within the last 5 years, along with a PASS/FAIL result. In the example below, the product under review is an L1970 for the Right side. The results show that a company billed a L1970 RT in May 2020 and that claim was allowed. Due to the 2020 claim being allowed, the Same or Similar result is a FAIL, and an ABN will need to be provided to the patient. In this scenario there is an exact Same match.
When the result is a FAIL and there is No ABN attached, there will be an Early Warning box that appears on the PA to alert users that the claim needs an ABN attached to bill the patient. The ABN can be found on the product section of the PA. Clicking “x” clears the warning.
For this same patient, if the involved side is changed to a Left, a different result is seen. The result now reads “No Claims Found” as there were no same HCPCS codes plus laterality combination. The Same or Similar result is a PASS. While an ABN would not be required for Same or Similar, users should evaluate all applicable coverage criteria when determining the need for an ABN with each patient.
Similar HCPCS Scenario:
Changing the HCPCS to L1930 for Right side, will provide the result for a same/similar grouping where the Same HCPCS was not found, but it is part of the larger AFO/KAFO Similar grouping. In this scenario users will see ‘No Claims Found’ with a FAIL result because similar claims were found within the RUL even though there were no same HCPCS claims found. An ABN is necessary in this example.
Important Note: Use the PASS/FAIL result and not the ‘No Claims Found’ result when determining the need for an ABN.
Additional Information & Error Handling
Product Order on PA
The Same or Similar check can only be completed for one product + HCPCS code combination. It is set to only check the first product/HCPCS code on the PA. If a patient is receiving both an L and an E code product, add the product with the L code to the PA first. If there are two L code products, the results will provide PASS/FAIL for the first product only. The second L code product would need a manual review to determine PASS/FAIL.
If multiple requests are completed on the same patient agreement, the Same and Similar history is tracked when viewing results. The requests are newest to oldest with the newest on the first page. The date and time of the results are also captured.
Should an error occur, a note will appear along with a Show Errors button. Click the Show Errors button to view the error message. Depending on message additional actions can be taken to resolve
Missing State Code Error
When the Error modal opens, if the reason is State Code is Missing, Edit the Medicare Payment Method, add the 2-character State Code under the Customer section and Save. Click the Send Request button on Same and Similar to rerun the check
Invalid Beneficiary Name or Date of Birth
Another potential error is related to the patient name listed within the Payment Method section not matching exactly what Medicare has within their portal. The most common error occurrences are caused by suffixes i.e. Jr, Sr or II and III at the end of the last name. Additionally, if a nickname or middle name is being used as first name, an error may occur.
To correct the patient name or DOB, Edit the Medicare Payment Method, update the patient name or DOB and Save. Click the Send Request button on Same and Similar to rerun the check
The error message may look like either of these views:
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