May 25th, 2021 - TammyC
GA GY necessary on therapies not covered by Medicare?
Hello. I work for a chiropractor. I have been getting denied on therapies for non- coverage with a secondary insurance. So my question is; If a patient has Medicare as a primary and BCBS Federal as a secondary ins. which covers therapies on this patients plan, is it necessary to use Modifiers GA GY since Medicare does not cover therapies. Thank you for your help.
May 25th, 2021 - ChrisW 256 1
re: GA GY necessary on therapies not covered by Medicare?
First, what is the actual reason for denial? You want to look at the benefits for the primary (Medicare) and ensure you are billing correctly and the treatments are reasonable and necessary. I have attached a fact sheet on Medicare coverage for Chiropractic Services.
If you are doing maintenance therapy and you know it is non-covered, you must use the Modifiers GA and GY on your claim. Be sure Medicare is the Primary and BC is showing as the secondary on your claim form; even if it is not covered, you still need to get the denial from the primary so you can bill the secondary, and both payers should be on your claim form. BCFed should be a cross-over, meaning Medicare will send the claim to BC if it is on your claim. If not, do not send a new claim showing BC as the primary; it does not work that way.
If you are only doing maintenance, it may not be a covered benefit. If Medicare denied it then BC will likely deny it, BC often follows Medicare's rules and policies.
To ensure you are billing correctly, look at your payer policies and LCDs for your MAC; they will give you information on which diagnosis codes should be used as primary or secondary; for example, take a look at this one for WPS Billing and Coding: Chiropractic Services (A56273).
Be sure you have an ABN on file if you know it is a non-covered treatment.
Another great resource, you may want to consider purchasing is the ChiroCodes 2021 Desk Book.