GA Modifier- response

GA Modifier- response

Randall McFarland, CPO

Here was the question I posted...

Hello List-members,
     It was suggested at the recent L-coding seminar that the GA  modifier
be used whenever we bill for an item that we believe to be non-covered.
 Some practitioners I've talked to are concerned that this might be a red
flag which would likely trigger automatic denial.  
     Have any of you had experience using the GA modifier? Has it
influenced payment in any way?  Regardless, when you bill say, L8499
(unlisted procedure), you'll likely need to have very good documentation,
explaining the medical necessity of the item (NOT for convenience or
 comfort) to have a chance of getting paid.
     For instance, a donning tube would likely be justifiable if it were to
prevent damage to the recent surgery, while if it were only to prevent
discomfort when donning a shrinker, it wouldn't be covered.
     I will post responses. If you don't want your name included, put it in
parentheses.

Have a good weekend!

Randy McFarland, CPO

Here is the response received .

I've used the GA modifier routinely.  It's not only useful, it's absolutely
necessary.  For instance, if you sell shoes to a Medicare patient who is NOT
diabetic, nor a partial foot amputee, nor wears a brace which would be
attached to the shoe, if you don't tell the patient and get a written
acknowledgment prior to billing, you can be made to give them the item and
not allowed to bill them AND you are subject to a possible $1000.00 fine per
incident!  When using the GA modifier, you must be specific, when you tell
the patient that an item will not be covered, as to the reason why it is not
covered.  DMERC Region C has not appeared to me to hold it against us in any
way.  Nor do they use it to disallow.  On the contrary, both my son and I
have seen payment EOMB's where patients have been paid when we thought they
wouldn't.
     Besides shoes; arch supports, any item for personal convenience or any
non
prescribed item need the GA modifier.  As an example, in Florida, the law
requires me to have a written prescription for anything that I sell,
dispense, apply (call it what you may).  However, I can duplicate any
appliance that a patient already has provided that I do not change the
prescription.  If a Medicare patient comes in and wants a new KAFO to
replace the old, badly worn one that he/she currently uses, I can provide a
new KAFO to the same prescription.  If that patient refuses to get a
prescription, by Medicare law, it will not be covered.  You need to use the
GA modifier AND you need a signed waiver of liability.