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MODS GA & GY

Alea Posted Sat 01st of December, 2012 00:56:35 AM

Can you clarify between the 2. which one do we use for supply of BCL 99070. Medicare & most other insuraces pay for insertion of BCL 92071 but not supply 99070.

SuperCoder Answered Tue 04th of December, 2012 22:00:42 PM

Hi,

This we have sent to our editors. You will hear back soon.

Thanks

SuperCoder Answered Tue 18th of December, 2012 15:44:25 PM

Modifier GA and GY are used for services provided to Medicare patients only.

Prior to the patient being fitted with the BCL, an ABN (Advance Beneficiary Notice of Non-Coverage) should be completed to notify of possible non-payment for the supply. The ABN is required for services that are covered by Medicare but under certain circumstances, the service will not be covered (utilization limit, diagnosis, etc.).
However, the ABN is not required for services that are always considered non-covered by Medicare (refractions, cosmetic procedures,
etc.) CMS does recommend obtaining the ABN for non-covered services in an effort to inform the patient of their financial responsibility.
Again, an ABN is not required for services always considered non-covered, just recommended.

Remember that it is the BCL supplies that are not covered (not the
procedure) that should be indicated on the ABN. Be sure to use language on the ABN that is easily understood by the patient. Do not use CPT/HCPCS codes to convey this information as that is not patient-friendly language. Always specify the estimated cost to the patient on the ABN.

When submitting the charge for "sometimes covered" services following a fully executed ABN, modifier GA should be appended to the code.

When submitting the charge for "always non-covered" services, with or without an ABN, append modifier GY to the code.

In the case you describe below where the supply is always non-covered by Medicare, the supply may be submitted with modifier GY to let Medicare know that you are aware the supply is always non-covered but you need Medicare to provide you with an EOB on non-payment to submit to a secondary insurance.

Alternatively, you may be able to submit your claim using one of the HCPCS Codes for the BCL supply -- V25XX. In this case, it may be more appropriate to append modifier GA (following propoerly executed ABN) to the V25XX code. I am uncertain as to whether or not Medicare will pay for the supply using the HCPCS code.

In either case, you are letting Medicare know via the appendage of modifier GA or GY that the expectation is the BCL supply will not be covered and the patient has been informed of their financial responsibility for the supply.

CPT Code 92071—Fitting of a contact lens for treatment of ocular surface disease. This is the appropriate code to use for fitting a bandage contact lens. Report materials in addition to this code, using either 99070 or the appropriate HCPCS Level II material code (V25XX).

CPT Code 92072—Fitting of a contact lens for management of keratoconus, initial fitting. For subsequent fittings, use either the 9921X or 9201X codes and report materials in addition to this code, using either 99070 or the appropriate HCPCS Level II material code.

Do not report 92071 and 92072 on the same day of service.

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