Many clients have asked how to bill Medicare for custom foot orthotics when the patient’s secondary insurance does, but must first be rejected by Medicare?
This scenario is almost a daily occurrence in many busy practices catering to the senior population. While not difficult it does require some basic knowledge of third-party payer rules, Medicare modifiers and Medicare DMEPOS enrollment.
I have often heard from many practitioners that they are not enrolled in Medicare as a DME provider because of all the hassles and they don’t do any DME other than foot orthotics. Thus, they have no incentive to enroll. To obtain a rejection from Medicare on foot orthotics, one must be enrolled as a Medicare DMEPOS provider and submit the claim to the proper DME MAC jurisdiction. The latter of which is based on the patient’s legal address, located in the Social Security Common Work File.
More importantly, if one is not enrolled as a DMEPOS provider, one cannot submit a claim to the DMEPOS provider and obtain a PR (Patient Responsibility) rejection. Instead, the claim will be rejected on the front end and returned as non-processable. In simple language, the claim will be outright rejected and not passed onto the secondary carrier for processing.
Patients do have a once in a lifetime benefit to self-submit claims for processing (CMS Claim Form 1490). This form may be found on this link.
It is rather unfair to ask a patient to use up this benefit for a claim which will result in a non-payment by Medicare and potentially reap such a relatively small benefit from the secondary carrier.
Assuming your practice is enrolled in Medicare, the process is rather simple. Complete and submit claim form as you normally would (as explained in the previous installment) to the proper DME MAC. The HCPCS code (L30XX) should be amended with the GY modifier and the RT or LT modifier should be second. The GY modifier is a Medicare payment modifier which will tell the DME MAC to process the claim with a PR (Patient Responsibility) remark. If the patient’s Common Work File has a secondary insurance, then the claim will automatically cross over to the secondary. If the patient’s Common Work File does not contain a secondary insurance, then one can simply photocopy the Medicare EOMB PR rejection and submit a claim to the secondary.
If the secondary carrier covers custom foot orthotics, then in most cases that is all that will be required for the secondary carrier to cover the claim.
In some rare circumstances when the GY modifier appears on the Medicare EOMB there are secondary carriers which will also reject payment. If that is the case, then some lengthy discussion with the secondary carrier to process the claim may be required.
The next and last installment in this series on billing of custom foot orthotics will include some controversial subjects such as the billing for gait analysis and the actual fitting and adjustment of the custom foot orthotic itself.
