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I work for a varicose vein specialist. We are not contracted DMEPOS providers. Our patients are required to go through a conservative therapy trial period prior to treatment by most insurance companies. They are required to wear compression stockings. Code A6531 is an example. Do I need to have an ABN signed for this purchase? Do I have to submit the claim and if I do should it be with a GA or GX modifier? I am having a very difficult time getting this figured out. Can anyone advise on the proper way to bill for this item?
You cannot use an ABN in this situation. ABNs are for services that you provide which are normally covered but which you expect may be denied because of the patient's particular condition or situation may not meet the requirements for coverage in that instance, usually due to a NCD/LCD policy. An ABN can't be used because you are not a contracted DMEPOS provider. If this item would a covered benefit from a credentialed or contracted DMEPOS provider, you should be referring your patients to that provider to obtain the item.
Thank you for your response - greatly appreciated. If they decide not to go to a DMEPOS provider to purchase them and purchase them through us do I have to have something in writing in their file to prove they had the option to go elsewhere and have a claim submitted?
For patients covered by commercial plans, you are really only restricted by the terms of your contract so that may or may not be an issue. But if this is a Medicare or Medicaid patient, I believe it would not be compliant to sell or give these items to the patients, even with 'something in writing'. If you bill a DMEPOS item to your Part B carrier, it will be denied, the EOB will state that the patient cannot be billed, and you cannot use a waiver to get around this. And since the EOBs are sent to Medicare patients' homes, if patients have paid you and then see on the EOB that they do not owe you for the item, it's quite likely that someone will report this to Medicare. Most Medicaid plans also severely restrict the circumstances under which you can collect a payment from the patient. I strongly advise against trying to get around these requirements. If your practice wants to provide these items to these patients, it should to go through the required steps to do so.
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