Billing Medicare for Denial: Tips to Ensure Your Home Infusion Claims Are Payable by Secondary Payers
By: Cheri Sciacca, Mediware Reimbursement Services
If you provide services to Medicare beneficiaries, you’ve probably already discovered that some types of IV care are covered only by secondary payers or are not covered at all. When a secondary payer is an option, you typically are required to bill Medicare first to obtain an acceptable denial, which then allows you to submit your claim(s) to the secondary payer. Billing Medicare for services for which patients don’t qualify or that are statutorily excluded can be a bit tricky. However, these tips can help you ensure that your processes are accurate, which will enable you to collect from secondary payers without delay.
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- Medicare denials are needed when:
- Patients receive services normally covered by Medicare but do not meet the Medicare coverage criteria (such as short-term TPN or enteral therapy). Short term is defined by CMS as 90 days or less.
- Patients receive services using infusion pumps that are covered for specific drugs, conditions, etc. (such as most types of antibiotics and some types of hydration) but are not covered for the services you are providing
- Patients receive services that are statutorily excluded from the Medicare policy (such as catheter care) Note: Some secondary payers will allow you to bill directly to the payer and bi-pass obtaining a Medicare denial from some statutorily excluded services.
- Each team member plays a role in obtaining the denial:
- Intake and/or clinical staff need to know how to qualify patients before services are rendered and obtain ABNs (Advance Beneficiary Notices), CMNs/DIFs, and/or all other required documentation.
- Billing staff need to know how to correctly bill for non-covered services using procedure codes that are acceptable to Medicare – whether in kit or per diem format. They also need to know which modifiers need to be assigned to the patient’s claims, and know the documentation required with any initial claim.
- Collection staff need to be aware that these denials are correct and know the processes for sending claims to secondary payers in the secondary payer’s correct format.
- Codes to use when billing for:
- Infusion supplies when infused using an external infusion pumps, per cassette or bag – code A4222 plus the GA modifier presuming you have a signed ABN dated on or before your start date of service, along with the DIF and other supporting documentation.
- Infusion supplies not infused with external infusion pump, per cassette or bag – code A4223. A modifier is not required nor is an ABN or a DIF.
- Supplies for maintenance of drug infusion catheters, per week bag – code A4221 with the GY modifier.
- NOTE: Have your ABN and DIF information ready before billing, so you can ensure these claims are correctly processed. If you neglect to add a modifier when billing for denial, Medicare could end up paying rather than issuing the denial and EOB that you need for the secondary payer.
What do these modifiers represent and why are they used?
GA Modifier: Waiver of Liability Statement Issued as Required by Payer Policy
This modifier indicates that an ABN is on file, allowing providers to bill patients IV services not covered by Medicare. Use of this modifier ensures that, upon denial, Medicare will automatically assign liability to beneficiaries.
GZ Modifier: Item or Service Expected to Be Denied as Not Reasonable and Necessary
This modifier indicates that an ABN was not obtained and signifies that denial is expected due to lack of medical necessity.
GY Modifier: Notice of Liability Not Issued, Not Required Under Payer Policy
This modifier is used to obtain a denial on a non-covered service. Use this modifier to notify Medicare that you know this service is excluded.
When billing Medicare for home infusion items with the intent of receiving denials, your keys to success are the appropriate billing codes, modifiers, and supporting documentation. Once these claims have been denied, you can begin the process of collecting from secondary payers and patients.
To ensure your claims are billed correctly, put your trust in Mediware Reimbursement Services. Our reimbursement team has over 60 billing professionals that have proven results to maximize your collections and reduce your bad debt. Learn more about home infusion billing services today!