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Linda Collins Blogger

Medicare Does Not Cover All Devices

Posted by Linda Collins | April 04, 2018

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 Ankle-Foot Orthosis (L33686) states that a walking boot used for pressure reduction or lower extremity ulcers is a not covered.

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 patient makes the specific request. Even then, you may collect payment up front.

If you do submit a claim, use submit the GY modifier. This modifier states the item is 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. Do not use the GY modifier on these claims.  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.

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