This document was created by Paul Kesselman, DPM, CEO of Park DME Consulting, LLC.
Most third-party payers, including all Medicare and commercial insurance, have a “Same or Similar Policy” precluding coverage for a replacement AFO during the five-year period after first receiving an AFO. This is similar to the post operative surgical global period enforced on surgical reimbursement.
As with surgical global periods, most if not all third-party payers, have created exceptions to the Same or Similar Rule. But unlike surgical global periods, there is no special modifier to avoid the majority of Same or Similar denials.
Therefore, there is much confusion how to either bypass or appeal the Same or Similar.
Traditional Medicare does offer a process by which Same or Similar denials may be appealed, allowing for additional payment for a replacement AFO under certain conditions.
Medicare Advantage AND COMMERCIAL CARRIERS: IT IS BEST TO OBTAIN YOUR APPEAL RIGHTS AND METHODS DURING THE PREDETERMINATION OF BENEFITS AND PRIOR AUTHORIZATION PROCESS WITH THOSE CARRIERS.
Workflows for addressing Same and Similar situation no matter the insurance issue are available on the TayCo website.
When appealing Same or Similar denials, your patient’s chart and cover letter must contain supportive documentation. That is, the chart must support why the current AFO is either antiquated, ineffective, or deleterious to the patients’ current needs and how a new/replacement device will address a change in condition or diagnosis.
Note that CAM Walkers and Night Braces are also considered AFO’s by all payers.
The following clinical examples may support the need for a new or replacement AFO
The AFO was lost, stolen, irreparably damaged due to a one-time event. In this case one should have a signed attestation from the patient along with corroborative evidence such as a police report, insurance report (homeowners, car, flood, etc.). These claims can be amended with the KX modifier and RA (indicating the AFO was lost stolen or damaged by a one- time event) and the site modifier (RT/LT or both).
A change in diagnosis or condition. Some common examples include:
- A change in anatomy where the current AFO no longer accommodates a boney protuberance, resulting in the previous AFO being unusable. Common examples include changes due to Charcot, PTTD, RA, etc.
- Soft-tissue changes, such as ulcers or skin lesions, abrasions, that the previous AFO caused or accentuates and cannot be ameliorated despite numerous adjustments. This often may be accompanied by a new or worsening condition.
- New Pre-ulcerative calluses due to bony prominence or deformity which cannot be accommodated by a repair of the currently used AFO
- A change of function of the patient. Example 1: stroke or any motor disease or sensory disfunction with newly-diagnosed diabetes, spinal stenosis or a new balance (such as MS, secondary renal disease, etc.). Example 2: back, hip, or knee arthritis with secondary antalgic gait that the walking boot accentuates and therefore unusable.
- Inability to use a previous AFO because of pain (secondary back, hip, knee) caused by the AFO. Example: walking boot secondary pain (lower back) due to leglength inequality gait.
- Significant overall body increase or decrease in patient’s weight (> or < 25lbs) where the current AFO fit despite adjustments cannot be used without significant issues for the patient.
- A new or worsening physiological need from when current AFO was dispensed. Adjustments have not resolved the issues for the patient. Common examples would include 1 - onset or change in CHF, venous insufficiency with secondary increase in leg girth, 2- worsening CHF or COPD where energy expenditures (observable shortness of breath or labored breathing) to use the current AFO exceed the patient’s ability to perform their ADL's because of current AFO weight and clumsiness it entails. In such cases, the new AFO would need to document the history of CHF or COPD. Supportive documentation from the patient’s treating CHF or COPD physician may be helpful.
- Inability to continue to use the current AFO because it does not control the patient’s 3 plane instability for the ankle/hind foot – sagittal (dorsi/plantar), transverse (abd/add), and frontal (inversion/eversion) – i.e. flail-type or chronic instability type ankle. Example: dorsiflex-assist AFO only controls sagittal, not all 3 planes. .
- A different diagnosis for the previous/current AFO than for a newly ordered AFO. Example 1: Current AFO for 5th metatarsal base fracture now with ankle fracture that needs a ROM AFO. Example 2: Current AFO for 5th metatarsal base fracture now with OA of the same ankle that needs a long-term brace (>6 mo.) requiring a custom fabricated AFO.
- Progression of Care from fixed to limited ROM to full ROM. Patient needs to transition from an acute condition requiring AFO (e.g., a fixed walking boot) to a AFO more suitable for rehabilitation (AFO with ROM hinges) allowing for stretching, strengthening mobility, gait, and functional gains for ADL.
- The previous AFO did not correct the previous deformity(ies)
- Patients new occupation or home residency requiring different functional requirements than with present AFO.
- A pre-fabricated, custom fit AFO does not fit and needs now a customfabricated AFO. Example: type 2 PTTD and AAFD.
- Patient’s new occupation or home residency requiring different functional requirements than present AFO.
TayCo Brace recommends taking photographs at various dates of service both prior to ordering a new/replacement AFO. For example, when repairs are attempted, when a new AFO is ordered and casted for and/or when the new AFO is dispensed and at regular interval follow ups.
Note that for change in condition or diagnosis the only modifiers to be used are KX and site modifiers (RT and/or LT). The RA (replacement due to irreparable damage) and RB (repair) do not apply. Rules regarding additional payment modifiers are provided on TayCo’s ABN advisory.
The impact of Same or Similar cannot be eliminated but it can be minimized by following other resource documents available on TayCo’s customer support website. These include links and documents from CGS and Noridian, workflows for Medicare FFS (Traditional), Medicare Advantage, and other third-party payers, common clinical scenarios with proper documentation, appeal templates and video tutorials. We hope you find this information useful and welcome your questions. Please contact any of our customer service staff with any concerns.
Disclaimer
This document contains generalized information that is presented for informational purposes only and not specific for any one patient or circumstance. Providers are required to submit accurate and appropriate claims for the services that they provide. It is the provider’s responsibility to determine medical necessity and to submit appropriate codes, charges, and modifiers for services that are rendered. Providers should consult with their payers, reimbursement specialists and/or legal counsel regarding coding, coverage and reimbursement matters. The information in this document does not constitute medical, legal, or other advice, nor is any information intended as a promise or guarantee by TayCo Brace regarding coverage or payment for products or procedures by Medicare or other payers. TayCo Brace specifically disclaims responsibility for the results or consequences of any actions taken in reliance on information in this document.
