Author Topic: Billing Psych visit 90834 to Medicare for denial - confused about GY modifier  (Read 4024 times)

debfini

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Hello everyone - have been billing psych for 20 years and just now finding out information regarding billing Medicare for an Licensed Professional Counselor (LPC) - which is NOT covered my Medicare in Virginia.  I always send these via paper with letter stating that Medicare does not pay for services rendered by LPC - please deny and highlight on bottom of claim "This claim is for denial purposes only" (which is what Medicare told me to do years ago)... :-\  Then I submit denied EOB to secondary. 

Think I have been doing this wrong all along?  Should I be sending the HCFA to Medicare without letter, etc? And, instead send the HCFA with just a "GY" modifier?  With Psych - I have never used a modifier.

Please advise.. :-[.  Also I just saw that Medicare will not take the OLD HCFA's after 4/1/14.

Thanks to anyone that can guide me....

Debbie

rdmoore2003

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Medicare does not cover LPC's.   Why are you using a modifier?    If I have a patient that has medicare primary, I file to medicare electronically so that they can send crossover. 
Regina

Merry

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It only will cross over for Medigap plans.  Many secondaries are supplementals, which dont always cross over. 
More so.. If the specialty is not a covered benefit for Medicare how can one  even attempt to bill Medicare?  I am confused.  The provider would not be in the Medicare system at all.  Ok,  missing part of my brain here. 

debfini

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Merry and Rdmoore - This provider is not set up electronically because she is (opt-out) and because Medicare does not pay for LPC....so I do it all by paper.  I read this information on Medicare website and started second guessing myself as Medicare billing is not my forte'.  Most of my clients are fee for service or straight CareFirst/Anthem, so I feel inept billing Medicare.  Typically, I bill Medicare with my letter and such, then client sends me the denial.  I take denial and create paper claim to CareFirst attaching Medicare denial.  Provider eventually gets paid. 

However, after reading the Medicare website I thought I was doing this all wrong and thought I was supposed to be using the GY modifier.  Should not have second guessed myself because my system gets the provider paid and that is all that matters. 

I apologize for the confusion and I am not going on that website again!!! :-[

Thanks again....will leave well enough alone...

Regards,

Debbie

Merry

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Please.. Nothing to apologize about.  I just wanted to be sure that we understood you.  Please do hang out here.  There are lots of people here that bill mental health so stay in touch please.

Michele

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Debbie,

When the provider is not enrolled in Medicare (because Medicare does not enroll their specialty) I don't believe you are supposed to submit to Medicare.  You should be able to bill the secondary directly with no denial because the secondary should recognize the provider as not being able to enroll in Medicare.  They should process as if they were primary.  If you are submitting to the secondary on paper you could attach a cover sheet stating "Medicare does not enroll LPC therefore there is no Medicare EOB"  or something similar.
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PMRNC

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Many secondaries will NOT pay as primary. The patient really should be seeing a Medicare provider or they can pay out of pocket but the secondary may not pay without Medicare consideration. Makes sense, why would they assume primary liability on a beneficiary who has access to a provider who can bill Medicare. My dad runs into this now with his physicians that opted out.

On a good note, legislation was introduced last year to allow LPC's to be covered by Medicare.
Linda Walker
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shanbull

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Many secondaries will NOT pay as primary. The patient really should be seeing a Medicare provider or they can pay out of pocket but the secondary may not pay without Medicare consideration. Makes sense, why would they assume primary liability on a beneficiary who has access to a provider who can bill Medicare. My dad runs into this now with his physicians that opted out.

On a good note, legislation was introduced last year to allow LPC's to be covered by Medicare.

This is what we have to do, we have some people with dual Medicare/Medicaid policies that say in the eligibility info for Medicaid that FFS services must be submitted to Medicare first, no matter what, and the secondary insurance requires a Medicare denial to process the claim. If we try to bill the secondary without going through Medicare first, we get a denial from the secondary.

rdmoore2003

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On a good note, legislation was introduced last year to allow LPC's to be covered by Medicare.

Just waiting for Medicare to actually cover is the frustrating part.
Regina

PMRNC

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Quote
Just waiting for Medicare to actually cover is the frustrating part.

You have to think of this from another angle .. WHY should any other secondary payor assume primary responsibility/liability when the patient can be seen at a covered provider and reimbursed / considered by Medicare FIRST. Most carriers follow Medicare.
Linda Walker
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Michele

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It really depends on the secondary plan.  If it is a Medicare supplement obviously it won't be covered.  If it is a group plan then it depends on how the group plan is written.  I have seen many instances where a service or provider is not covered under Medicare but the group plan does allow for it.  In those cases, the Medicare eob is not required.  In the case where the secondary does require a Medicare eob, even if it is a denial, then that can be a problem, as you are obviously experiencing that.  Non Medicare providers cannot enroll to submit claims electronically so it's really a vicious circle.
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debfini

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It is a giant pain.  LPC's have been trying to get legislature together on this issue for the past 10 years.  I have tried to send to the secondary with letter explaining that Medicare does not cover and they seem to always send back stating that "the beneficiary has Medicare or another primary insurance"....

Thank you all for your comments as this board really is a wealth of information and experience.  Something you just can't get from a book or website!!

Debbie

PMRNC

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If it is a group plan then it depends on how the group plan is written.  I have seen many instances where a service or provider is not covered under Medicare but the group plan does allow for it.


ONLY Medicare carve out plans..

Yes some carriers will pay as primary for a service they KNOW is not covered by Medicare, most carriers do follow Medicare in that regard. In this case however the patient is not receiving a non covered service, they are receiving services from a non enrolled/non covered provider. The secondary plan is not going to assume primary responsibility/liability when the patient can receive the covered service by a covered Medicare provider.  But again, the provider can choose to see the patient out of pocket, give the patient a bill and let the patient submit to secondary on their own.
Linda Walker
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Michele

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There are some unusual situations.  Texas Medicaid allows LPCs to enroll even though Medicare doesn't.  In that case the patient can see an LPC even though Medicare does not enroll them and Medicaid will cover.  I know it is not the norm but I have seen a few other situations as well with acupuncture.
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