Patients often either are misleading, lie or simply are confused and can’t remember when they last received their therapeutic shoe/ inserts. How can you be as close to 100% sure that the patient is telling you the truth if they received their inserts during this calendar year?
For patients you have provided shoes/inserts under the Therapeutic Shoe Program, you need not look any further than your EMR/EHR. But what about new patients or patients you see sporadically through the year or who spend the winter elsewhere? How can you know for sure?
Each DME MAC has a provider portal where one can search for Same or Similar, and in the case of the therapeutic shoe coverage it is a per calendar year search. If you are in Region A or D you likely limit your search to the Noridian Provider Portal and navigate your way to the Same and Similar portal where you can search for the “A” codes for shoes and inserts. If you are located in DME Region B/C you would similarly look at this information in the MyCGS portal Same or Similar. However, limiting your search to your home portal is potentially misleading.
If the patient lives in a different DME MAC region than where your practice is located (e.g. a patient with a legal address of Florida who sees you in your California office) then your home DME MAC portal may not contain the information you need. Your office needs to perform a similar check for the portal for the DME carrier where the claim will go. In this case, that would be DME MAC C. Always make a copy of the results of your search as proof of the patient’s status. This could be very helpful in case an appeal is later required.
Same and Similar is as important for therapeutic shoe claims as it is for AFO claims. For therapeutic insert/shoe claims, the Same or Similar report will provide you with both the date of service and the name of the supplier who provided the patient with those services. Certainly, if that is within the same Calendar year and the patient has already received one pair of shoes and 3 pairs of inserts, then there would be no coverage for any additional services under the therapeutic shoe policy.
Under these circumstances, one should obtain an ABN and note that the reason the claims will not be expected to be paid is that the patient has already met the coverage frequency for that calendar year. Also, the ABN should state what was previously received and what you will now be providing. The modifier KX, would be replaced by GA, which indicates that the medical necessity and frequency of service has already been met. The use of LT and/or RT is unchanged.
The claim would then be denied under PR (Patient Responsibility) and could then either be processed for payment by the secondary insurance company (if there is additional coverage) or also denied if there is no additional coverage.
To sum up, using the provider portal is efficient and provides you with as close to 100% accurate information as possible.
