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Same or Similar – Medicare

Medicare has recently made updates to its “Same or Similar” device policy. As you may know, Medicare limits the number of braces that can be provided to a patient within a certain time frame, usually five years, for most devices. However, they have expanded the list of devices that are considered “same or similar.” This policy affects all types of braces, but most recently we have had difficulty providing custom ankle braces for patients who have recently been given an off the shelf device “until their new brace is ready.” When you bill for an off the shelf brace, of any type, Medicare will deny custom bracing for that same condition or diagnosis. You can no longer bill for a device to “hold them over” while waiting for custom bracing to be completed. This includes lace up, or wrap around ankle gauntlets, walking boots, off the shelf AFOs, and the like. Wrist braces, back braces, neck braces, knee braces, are also included in these
policies. If your office bills for these devices, then you patient will bear the responsibility of the bill for their custom bracing, should you decide to prescribe for it.

It is possible to provide an off the shelf brace for a patient that you believe only has a temporary need for bracing, and then prescribe custom bracing then you determine that the need is more long term. Also, you can prescribe custom bracing after you have determined that off the shelf bracing is not supportive enough, or no longer meets that patient’s need for control because a deformity is, or has become, multiplanar. You can also prescribe custom bracing if the patient has had a change from their original condition, or diagnosis for which you provided an off the shelf device originally, like weight gain, or a newly discovered fracture. In all cases, Medicare will require that you have an in-person visit with the patient and document the need that requires you to change from off the shelf bracing to custom. At minimum, the documentation should indicate that off the shelf bracing was tried but found to be insufficient. After that point, we can help you to clarify the insufficiency through an addendum to your notes.

We understand that this is another complication in the long list of responsibilities that you have in caring for your patients. Please understand that we also are looking out for your patient’s physical and financial health in bringing this to your attention. We would be happy to arrange to meet with you, in person, to discuss how we best help you navigate these changes with minimal disruption to your current office processes. We can help you understand what documentation is needed to best provide short, and long term, bracing care for your patients.

Same or Similar Chart on Noridian’s website.

Same or Similar Denials on Noridian’s Website