Myth #1: If an item is not coded, it does not have to be billed.
First, every “potentially covered” item has to be billed as a result of federal guidelines in the Social Security Act. If Medicare ever pays for the item, then you have to file the claim, even if you do not expect it to be covered for a specific beneficiary. This is often referred to as mandatory submission of claims: “The Social Security Act (Section 1848(g)(4)) requires that claims be submitted for all Medicare patients for services rendered on or after September 1, 1990. This requirement applies to all physicians and suppliers who provide covered services to Medicare beneficiaries, and the requirement to submit Medicare claims does not mean physicians or suppliers must accept assignment.”
Second, manufacturer product coding is generally voluntary unless mandated by the DME MAC. When coding is voluntary, the onus is on the supplier to make the best coding decision using existing codes and product characteristics. If it looks like a standard walker, acts like a standard walker and functions like a standard walker… then the claim should be filed using a standard walker HCPCS code (even if the vendor has not submitted the item for coding). However, a few items are subject to mandatory coding. Refer to the LCD for instructions and requirements for billing scenarios where mandatory coding is required by the MAC, but has not been secured by the manufacturer. Only in the event that the LCD provides for a statutory exclusion does claim filing become voluntary.
Do you have a question you want us to cover for this series? Post a comment below or email us at email@example.com with the subject “MythBuster”. Then stay tuned for more myth busting from Andrea Stark and MiraVista.