Insurance Committee Report

Important DME Update

The DME MACS have begun enforcing a long standing policy of “Same of Similar”. Providers who dispense DME products will start getting rejections – reason codes – M3 – which means that the beneficiary has had a similar DME produce within the past 5 years.

The “Same or Similar” policy states that a beneficiary cannot get another AFO
(L code device) for the same limb written in a 5-year period unless the AFO is lost, stolen or irreparably damaged or the patient has a new diagnosis. You can sign up for the DME Portal on each DME MAC Homepage and do a search to see if your patient has had any of the “Same or Similar” devices in the past 5 years.

Please note that these restrictions can be overturned with submission of medical documentation. Also be aware that you might have to search under the new alphanumeric Medicare Number and the old Medicare Social Security Number—

Medicare (CMS) Announces changes to E/M Documentation Requirements

  • Effective January 2019 – please be aware of the following:
  • Do not have to document history and exam for each visit unless something has changed.
  • Can use information entered by ancillary staff and do not have to re-enter it.
  • Medical necessity for a home visit as opposed to an office visit does not have to be documented.

In 2021 CMS plans to merge Level 2, 3, 4 visits codes into one code so keep abreast for this change.

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