06/08/2017

Billing L3000- MCR (Primary) and Other Secondary Insurance

When submitting charges for L3000 for a patient with Medicare primary and other insurance secondary, should the initially billed GY modifier be carried to the secondary insurance or changed to the KX modifier we would have used if the patient did not have Medicare primary? We want to be sure we are billing the secondary appropriately. Thank you.

If the patient has Medicare coverage as primary, any orthotic HCPCS code should be billed with only the LT and RT, as well as the GY modifier to DMERC.  This assures the claim to be properly processed by the carrier and applied to patient responsibility. The remit code states PR (Patient Responsibility), which is necessary in order to bill the non-covered service by Medicare to the secondary insurance or the patient.

Orthotics are a non covered service by Medicare and under no circumstances should the KX modifier be billed with orthotics for a patient enrolled in traditional Medicare. The exception to this rule is, if the patient has some sort of foot or toe amputation.  If billed with the KX inappropriately, the item will be paid by Medicare in error. This will result in a payment that will be retracted in the future, and may also trigger an audit.