Wiki Durable Medical Equipment Breast Prosthesis

[ashleybabineaux]

Hello,
I currently work for a durable medical equipment company who specializes in Radiant Impressions, Custom Breast Prosthesis. We are trying to bill Medicare as Primary with L8035 and GA modifier to try and get a PR204 denial, so we can bill the patients secondary insurancec for payment. I wanted to ask and see if anyone has ever had expierence with this and if this is correct. Also I wanted to note that some of our patients have already recevied some breast prosthesis (usually a L8020 or L8030) and Medicare only allows for one a year, but considering we are not trying to get reimbursed from Medicare (just a patient responsibility denial) and L8035 is not a payable code by Medicare; Should this pose a problem? I hope some one can help. Thank you.

 

[ajs]

I am not well versed in breast prosthetics, but this is a covered code as far as I can tell. If you know it not to be covered, then you cannot use GA modifier as it is not allowed with this HCPCS code. You would use the GZ modifier to indicate you know it is a non-covered service and no ABN is required. This is how the information comes up in Encoder Pro.