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Understanding Medicare Modifiers For Insurance Claims

Updated

Description

This quick guide discusses the Medicare Part B requirement for including additional information to determine whether a procedure is medically necessary.

 

About

For patients with Medicare Part B plans, additional information is now needed for claim submissions to help Medicare determine if a procedure is medically necessary and would qualify for coverage.

 

Steps

  1. On the Edit Insurance Carrier page, a Carrier uses Medicare line has been added. The default response setting is No but will need to be changed to Yes if the carrier uses Medicare.


  2. To change to Yes, click No.


  3. A dropdown will appear. Click Yes.


  4. A new line, Default Medicare Modifier will now show. To add a modifying agent, click None.


  5. A dropdown will appear with three choices: GY - Not Medically Necessary, KX - Medically Necessary, and None. Click the desired option.

    Note: The selection chosen here (either GY or KX) will apply to all procedure codes billed out under the Medicare carrier selected at the top of the Carrier Information page.

      6. GY - Not Medically Necessary indicates that the procedure completed was not a medically necessary procedure and should not be considered for covered by Medicare. The majority of offices will likely fall into this procedure category.
      KX - Medically Necessary indicates that a procedure was medically necessary and should be considered for coverage by Medicare. This will be more prevalent in specialty offices.
      None indicates that there is no default Medicare modifier and will bill out as such, even if "Yes" was selected for Carrier uses Medicare.


  6. Medicare modifiers will be found under the Line Items dropdown on the Advanced Claim box. To expand and view line item details and the Medicare modifiers for each, click a line item.


  7. Medicare modifiers and line item details will show. The modifier chosen at the carrier level is the default modifier. To change the Medicare modifier, click the modifier.


  8. A dropdown of Medicare modifiers will open. Click the desired modifier.


  9. If a manual claim is selected, this is how Medicare modifiers will appear on a manual claim.


  10. To electronically submit a claim, click Send to Batch. Note: Medicare modifiers will also work for multi-claims.


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