Chapter 14 Reality Check Billing and Reimbursement

Chapter 14 Reality Check Billing and Reimbursement

Medicare will not pay for services or supplies that are considered experimental for a stated diagnosis. There are, however, cases where a provider has determined that such treatments are completely justified for the patient’s diagnosis. Medicare regulations specify that the provider must refund any payment received from a patient for a service denied by Medicare as investigational, unnecessary, unproven, or experimental unless the patient agreed in writing prior to receiving the services to personally pay for such services.

An example would be Zaza LeMore, who is an 85 year old healthy female Medicare beneficiary who has been evaluated for possible cosmetic surgery on her eyelids, even though she is able to pass her vision exam. She states they do not open wide enough and are distracting to her. The plastic surgeon shares with her that cosmetic surgery is excluded from the Medicare program. In order to proceed with the procedure, she must sign an Advanced Beneficiary Notice of non-coverage (ABN) so that she will be billed for all of the expenses associated with the procedure. The coder’s responsibility is to add modifier −GY to all procedures and services so Ms. LeMore receives all of the bills.


What is modifier −GY?

Do you feel this service is experimental or necessary?

What would happen if the patient refused to sign the ABN?

 chapter 14  Reality Check Billing and Reimbursement
Solution Preview

Medicare in the United States of America.

LeMore is a senior woman in need of cosmetic surgery hence the Medicare insurance system in the USA remains tasked with handling the billing of services rendered to signatory patients like her. Nonetheless, the fund might revoke payment when the procedure being administered is not only experimental but also unnecessary. Therefore, the terms of this waiver of liability are usually presented in the form of modifiers. The Medicare offers a variety of modifiers each specifically suited to handle a particular scenario.

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