Medicare Modifiers:12 Billing Mistakes You Might Be Making

To accurately report your optical dispensary’s services and supplies that you provide to your post-surgery patients, you must ensure that your Medicare claims forms include the right supply codes and that you’re applying these four key Medicare modifiers to those codes. Otherwise, your claims will be incomplete—and ultimately denied.

Keep These 4 Medicare Modifiers Handy

  1. To show that you have an ABN signed by the patient and on file for a particular non-covered item, you’ll append HCPCS modifier GA [Waiver of liability statement issued as required by payer policy, individual case] to the item’s code, advises Krystin Keller, CPC, who spoke about Medicare coding at a previous year’s SECO conference.
  2. Append modifier GY [Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit] “when a procedure is always excluded from Medicare’s payable benefits and you require a denial from Medicare to process the claim through the patient’s secondary insurance,” says Keller.
  3. You’ll report modifier EY [No physician or other licensed health care provider order for this item or service] with supply codes “for tints, A/R, and extras not prescribed by the doctor to show that the add-on was not prescribed by the physician,” according to Keller.
  4. For items that the doctor prescribes but that Medicare normally doesn’t cover, says Keller, append KX [Requirements specified in the medical policy have been met] to the supply code and ensure the patients signs an ABM form.

8 Common Reasons Medicare Denies DME Claims

As a DMEPOS supplier, you’ll have an easier time recouping pay for your dispensary’s post-surgery eyewear if you can prevent these claim form errors and process glitches , highlighted by Mary Pat Johnson, COMT, CPC, COE, CPMA, who spoke about post-cataract eyewear coding at a previous year’s Vision Expo West conference:

  • Wrong date of service

  • Wrong place of service

  • incorrect HCPCS code

  • Wrong copayment

  • Failure to collect for non-covered items

  • patient did not sign forms

  • no proof of delivery

  • Misuse of Medicare modifiers

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