“Is there a foolproof way to deal with the “Medicare doesn’t cover orthotics” issue? Is there an article that explains to the irate patient on the difference between functional orthotics and diabetic insoles and what is covered by Medicare? In this scenario, we typically explain to the patient that orthotics for plantar fasciitis are not covered. We have them sign an ABN and we can easily send the L3000 into Medicare with the GY modifier. We can share this with the patient and they can see that it is not covered. However, what can we do when the patient calls Medicare themselves and are told that orthotics are covered?”
Orthotics, that is classic, custom orthotics, are statutorily NOT covered by Medicare. “Well, I called Medicare and they told me that orthotics are covered.” Don’t you just love it when this scenario happens? What do you do?
Well, first of all as far as hard copy proof is concerned to support the fact that standard, classic orthotics are not covered by Medicare, you need to access and download the following: Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services. You then scroll down to 290 – Foot Care, and proceed to the following:
B. Exclusions from Coverage
1. Treatment of Flat Foot
The term “flat foot” is defined as a condition in which one or more arches of the foot have flattened out. Services or devices directed toward the care or correction of such conditions, including the prescription of SUPPORTIVE DEVICES, are not covered.
3. Supportive Devices for Feet
Orthopedic shoes and other SUPPORTIVE DEVICES for the feet generally are not covered. However, this exclusion does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics.
Orthotics are classified as SUPPORTIVE DEVICES.
Even though orthotics are statutorily non covered by Medicare, I believe that it is important to have an Advanced Beneficiary Notice of Non-coverage (ie. ABN) filled out and signed by the patient despite the fact that it is not a requirement in a scenario such as this. Why?
This is the only hard copy proof that you have in your possession as the provider that the patient was told that the service is not covered, why it is not covered and how much they will have to pay out of pocket if they choose to be provided with this service. If the patient insists that you still submit the claim to the Medicare Administrative Carrier based upon the fact that they were told by Medicare that orthotics are covered, it is important to file the claim in the following fashion for example:
L3000 – RT, GA
L3000 – LT, GA
It is important to use the GA modifier which is defined as the following: NOT REASONABLE AND NECESSARY with ABN – Use this modifier on a service or item code when you want to indicate that you expect Medicare to deny the service or item as not reasonable and necessary and you have a signed Advance Beneficiary Notice of Noncoverage (ABN) on file. You should not submit a claim for a non-covered service unless the patient insists that you do so.
What about the GY modifier? There are certain patients that have these super, great secondary supplemental health insurance plans that will pay for custom orthotics even though Medicare will not. Often these patients are retired government employees or retired teachers. Once you confirm that the secondary insurance will indeed pay for the orthotics, here is what needs to be done:
You do not need the patient to sign an ABN due to the fact that you have confirmed that someone is going to pay for the orthotics. Since Medicare is the primary health insurance carrier, you first need to submit the claim to Medicare in order to get the rejection EOB which can then be sent on to the secondary health insurance carrier which has been confirmed will reimburse for orthotics. Here is where the GY modifier comes into play. The GY modifier is defined as the following:
NON-COVERED – Use this Medicare modifier on a service or item code when you want to indicate that the service or item is statutorily non-covered or not a Medicare benefit. A claim with –GY will auto-deny.
Here is how the claim should be filed:
L3000 – RT, GY
L3000 – LT, GY
This is my opinion.
Michael G. Warshaw
DPM, CPC
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