A4466 - Garment, belt, sleeve or other covering, elastic or similar stretchable material, any type, each
A9270 - Non-covered item or service
K0672 - Addition to lower extremity orthosis, removable soft interface, all components, replacement only, each
K0901 - Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf
K0902 - Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf
L1810 - Knee orthosis, elastic with joints, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise How to bill non-covered self-administered drugs
The Centers for Medicare & Medicaid Services (CMS) provides instructions to contractors regarding Medicare payment for drugs and biologicals incident-to a physician’s service. The instructions also provide the contractor with a process for understanding if an injectable drug is “usually” self-administered (to mean a drug you would normally take on your own) and therefore not covered by Medicare.
• The term “usually” means that the drug is self-administered more than 50 percent of the time for all Medicare beneficiaries who use the drug, and are considered excluded from coverage.
Providers are not required to bill non-covered self-administered drugs, unless requested by the beneficiary or secondary insurance. If a line item denial is required that holds the beneficiary liable for the non-covered self-administered pharmacy services, the outpatient claim should be submitted as follows:
• Revenue code 0637
• HCPCS code that describes the services rendered; or,
• Use A9270 ( non-covered item or service) when there is no other appropriate code
• Modifier GY (item or service statutorily excluded or does not meet the definition of any Medicare benefit)
• Reason code 31324 will append to the line item when the GY modifier is present, and holds the beneficiary liable
• Reason code 31947 will apply to the line item when the GY modifier is not present, and holds the provider liable
• Advanced beneficiary notice (ABN) is not required
• Charges non-covered
• Do not submit the charges as covered
The outpatient code editor (OCE) status indicator is ‘E’ (non-covered) when revenue code 0637 is submitted without a HCPCS. In order to bypass the return to provider (RTP) reason code W7050 (non-covered based on statutory exclusion), the charges must be submitted as non-covered or as outlined above.
• Reason code 31947 will apply to the line item when the charges are submitted as non-covered without a HCPCS, and holds the provider liable
Clarification on Use of A9270
HCPCS code A9270, Non-covered item or service, will remain an active code and valid for Medicare. A processing note will be added to the HCPCS file that states, “Only for use on bills submitted by DMEPOS suppliers.”
The GY and GZ modifiers should be used with the specific, appropriate HCPCS code when one is available. In cases where there is no specific procedure code to describe services, a “not otherwise classified code” (NOC) must be used with either the GY or GZ modifier.
The A9270 will no longer be accepted for services or items billed to carriers.
Use of the GA, GY, and GZ Modifiers for Items and Supplies Billed to DMERCs The new GY modifier must be used when suppliers want to indicate that the item or supply is statutorily non-covered (as defined in the Program Integrity Manual (PIM) Chapter 1, §2.3.3.B) or is not a Medicare benefit (as defined in the PIM, Chapter 1, §2.3.3.A).
The new GZ modifier must be used when suppliers want to indicate that they expect that Medicare will deny an item or supply as not reasonable and necessary and they have not had an Advance Beneficiary Notification (ABN) signed by the beneficiary.
The GA modifier must be used when suppliers want to indicate that they expect that Medicare will deny an item or supply as not reasonable and necessary and they do have on file an ABN signed by the beneficiary.
The GY and GZ modifiers should be used with the specific, appropriate HCPCS code when one is available. In cases where there is no specific procedure code to describe items or supplies, a NOC must be used with either the GY or GZ modifiers.
In cases where there is no specific procedure code for an item or supply and no appropriate NOC code available, the HCPCS code A9270 must be used by suppliers to bill for statutorily non-covered items and items that do not meet the definition of a Medicare benefit .
The information in this CR supercedes all information found in CR 1371, Transmittal B-01-30, Deletion of the HCFA Common Procedure Coding System (HCPCS) Codes A9160, A9170, and A9190 and the GX Modifier and Replacement with New Codes and Modifiers; Status Change to HCPCS Code A9270.
This Program Memorandum (PM) provides an explanation on the use of the new GY and GZ modifiers. These modifiers were developed to allow practitioners and suppliers to bill Medicare for items and services that are statutorily non-covered or do not meet the definition of a Medicare benefit and items and services not considered reasonable and necessary by Medicare. It also provides an explanation on the use of the GA modifier. The new modifiers will become effective January 1, 2002, with the annual HCPCS update. The Q3015 and Q3016 described in CR 1371 will not be implemented.
Use of the A9270
Effective January 1, 2002, the A9270, Noncovered item or service, under no circumstances will be accepted for services or items billed to local carriers. However, in cases where there is no specific procedure code for an item or supply and no appropriate NOC code available, the A9270 must continue to be used by suppliers to bill DMERCs for statutorily non-covered items and items that do not meet the definition of a Medicare benefit.
The issue of ABNs arises when billing cosmetic procedures.
In that situation, report the diagnosis as V50.9,-cosmetic non-covered and also report the CPT procedure code performed. Append the GY modifier, which indicates that it is a non-covered service, to the procedure code. The benefit of this modifier is the patient will receive a remittance advice stating their financial responsibility. If the patient requests a non-covered claim to be filed to Medicare, the provider must comply.
It’s not suggested to report A9270, Non-covered service, to Medicare especially with a GA modifier because the Medicare remittance advice will state the claim needs to be forwarded to the Durable Medical Equipment carrier (DMERC) since the code submitted is a HCPCS code.