Items Not Covered by Medicare in 2019
Medicare has defined certain products as not being eligible for coverage or reimbursement. If a particular device is excluded from Medicare coverage, it is acceptable to sell it as a cash item and accept payment from the beneficiary at time of delivery.
If a particular device is excluded from Medicare coverage, it is acceptable to sell it as a cash item and accept payment from the beneficiary at time of delivery.
Medicare has defined certain products as not being eligible for coverage or reimbursement. Typically, items that do not meet the definition of medical necessity, as defined in the Local Coverage Decisions (LCDs,) are not reimbursed by Medicare. For example, the LCD for AFO/KAFO states the brace must be a rigid or semi-rigid device used to support a weak or deformed body part or used to restrict motion in a diseased or injured body part. If the brace does not meet this definition, it is not covered by Medicare.
What does this mean for you?
If the item is not a Medicare benefit, it is acceptable to sell it as a cash item and accept payment from the patient at time of delivery. You may establish a reasonable retail price for the brace and collect full payment from the patient. You do not have to submit a claim to Medicare unless the beneficiary makes the specific request. Even then, you may collect payment up front. You will submit the claim with a GY modifier. This modifier states the item is service statutorily excluded or does not meet the definition of any Medicare benefit. The claim will deny as patient responsibility. It is not necessary to use an ABN in this situation.
When providing a non-covered item to a Medicare Advantage member, you MUST give the patient notice that a service will not be covered. In other words, you are required to use an ABN type of form for the patient to sign. You will then bill the Medicare Advantage plan for the non-covered item. The claim is submitted without the GY modifier. You may collect payment from the patient at the time of service.
In summary, for non-covered services provided to a traditional Medicare beneficiary you will collect payment up front and only submit the claim, with a GY modifier, if the patient requests the claim be filed. For a Medicare Advantage plan, you will notify the patient of their financial responsibility by using an ABN type form, collect payment, and submit the claim without the GY modifier.
Additional information is available in the "Items and Services That Are Not Covered Under the Medicare Program" brochure. You and your patient may check to see if an item is covered here.