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Linda Collins Blogger

The Right Way to Give a Custom Brace

Posted by Linda Collins | July 22, 2014

Payors only reimburse “medically necessary” care and devices. They don’t cover “quality of life” improvements. To use a vehicular analogy that insurers seem to universally embrace, they’ll provide you basic transportation (Sentra) but if you want a luxury ride (Cadillac), you‘ll have to pay the difference.

So how do you manage the patient who wants the Cadillac?

What you can do.

Chapter 20, Transmittal 120 of the Medicare Claims Processing Manual lays out the appropriate way to deliver an upgraded device to a beneficiary in conjunction with an Advance Beneficiary Notice. If you follow these guidelines closely, Medicare will pay for the cost of the basic product and you can limit the patient’s financial responsibility to the difference between that and the upgraded device you deliver.

There are 3 steps you must follow:

  1. Explain to the patient that you can provide her an upgraded item, but she will be responsible for the difference between that and the base item that Medicare will pay for.
  2. Have her sign an ABN confirming that explanation.
  3. When submitting the claim, put the code for the actual item provided (i.e., the updgraded item) on the first line of the claim using the “GA” modifier. List the code for the covered item on the second line using the “GK” modifier.”

Example:Your patient, Tiffany Trailhead, needs an OA Unloader Brace (L1843). However, she loves color coordinating her hiking clothes. She tells you she wants a custom-fit brace and needs it to match her favorite hiking outfit.

You explain to her that you can bill for a custom brace but Medicare will not pay for the customized color scheme she wants. You tell her that Medicare will pay for the cost of the basic brace that’s medically necessary and she’ll be responsible for the difference in cost between that and the upgraded version she wants. You then have her execute an ABN consistent with that discussion. Finally, you bill Medicare as follows:

L1844 – GA Custom Unloader Brace

L1843 – GK OTS Unloader Brace

Medicare will deny the first line as “not medically necessary with patient responsibility.”  It will then pay the second line according to its normal procedures so long as you adequately document medical necessity).

Both Tiffany and you will receive a statement showing her financial liability as the difference between the submitted charge for the provided item and the submitted charge for the covered item, taking deductible and coinsurance into consideration.

You can provide Cadillac services to your patients! Just make sure that you follow these guidelines.

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