Non-approved appliance

[Jeremy Hobbs]

Medicare E0486 Billing

[niermanpm]

Hi, What is the modifier that I use with E0486 NU to indicate that a Medicare patient is requesting a non-Medicare approved appliance? (like a dorsal). GA is the modifier for not medically reasonable and necessary, but this doesn”t seem the correct description… 🙂

[niermanpm]

Hi Guest! Well, I don”t want to say that biller is incorrect, but if it were me, I would follow the Medicare LCD 🙂 Modifier GY stands for: GY – Item or service statutorily excluded or does not meet the definition of any Medicare benefit.

[niermanpm]

Thank you. A biller told me to use E0486 with a modifier of GY. I guess that was incorrect?

[niermanpm]

Hi AODTC! Great question. Actually, the Medicare LCD states that if an appliance used that is not PDAC cleared for E0486, instead of using HCPCS code E0486 you should code is as A9270, which stands for: Non-covered item or service Here is the language from the LCD: “All custom fabricated mandibular advancement devices that have not received a written PDAC Verification Review must use HCPCS code A9270 (NON-COVERED ITEM OR SERVICE)” Hope this helps!

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