Patient had a Laparoscopy, surgical with removal of bilateral salpingectomy for sterilization. According to the CMS, Medicare does not pay for elective. sterilization. My dilemma is 58661 for this procedure is covered for medical reasons, just not for elective sterilization. No ABN was obtained. This patient has medicaid as secondary that does cover elective sterilization. Would it be correct to add modifier GY in this case?
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Question Question regarding coding 58661 to Medicare for sterilization
- Thread starter tblmt1966
- Start date
CBLENNIE
Expert
I don't think you can rebill this claim with the GY modifier based on the fact that NCD Sterilization 230.3 states the following:
Per the MLN Booklet Medicare Advance Written Notices of Non-Coverage you would need to issue an ABN based on the following:
I think your in a bit of a pickle here because 58661 isn't statutorily excluded in and of itself, the issue is that it isn't covered for the reason it was performed, sterilization. Per the MLN Booklet on ABNs explanation of modifier GY, I don't think it applies in this case.
However, all is not lost. This service may be covered by the patient's Medicaid benefits, the question is will they pay for a benefit that Medicare denied as provider contractual obligation and there is no patient liability.
I work for an insurance company that administers DSNP plans for our state's Medicaid program, and we would allow benefits for this service even though Medicare denied it provider liability because we know Sterilization isn't covered by Medicare. We actually do not require providers to submit claims like this to Medicare before the DSNP plan since we know Medicare won't cover the procedure.
I would suggest trying to get the claim paid by Medicaid and then depending on how they process the claim you may need to appeal it to them because it is a Medicaid service and even though Medicare denied it as provider liability, because 58661 performed for sterilization purposes is never covered by Medicare.
Per the MLN Booklet Medicare Advance Written Notices of Non-Coverage you would need to issue an ABN based on the following:
I think your in a bit of a pickle here because 58661 isn't statutorily excluded in and of itself, the issue is that it isn't covered for the reason it was performed, sterilization. Per the MLN Booklet on ABNs explanation of modifier GY, I don't think it applies in this case.
However, all is not lost. This service may be covered by the patient's Medicaid benefits, the question is will they pay for a benefit that Medicare denied as provider contractual obligation and there is no patient liability.
I work for an insurance company that administers DSNP plans for our state's Medicaid program, and we would allow benefits for this service even though Medicare denied it provider liability because we know Sterilization isn't covered by Medicare. We actually do not require providers to submit claims like this to Medicare before the DSNP plan since we know Medicare won't cover the procedure.
I would suggest trying to get the claim paid by Medicaid and then depending on how they process the claim you may need to appeal it to them because it is a Medicaid service and even though Medicare denied it as provider liability, because 58661 performed for sterilization purposes is never covered by Medicare.