Billing non-assigned: Myths, part 1

Andrea Stark
reimbursement consultant, MiraVista

Editor's note: In the wake of new market pressures, upgrades, non-assigned claims and cash sales are taking center stage, says industry consultant Andrea Stark. The market has changed and your business should contemplate the suitability of these options, but they are not appropriate in all cases, she says. This is the first in a series of mini-articles that break down the top myths of filing non-assigned claims and leveraging upgrades and cash sales.

Myth #1:  If an item is not coded, it does not have to be billed.

This is FALSE.

First, every “potentially covered” item has to be billed as a result of federal guidelines in the Social Security Act. If Medicare ever pays for the item, then you have to file the claim, even if you do not expect it to be covered for a specific beneficiary. This is often referred to as mandatory submission of claims: “The Social Security Act (Section 1848(g)(4)) requires that claims be submitted for all Medicare patients for services rendered on or after September 1, 1990. This requirement applies to all physicians and suppliers who provide covered services to Medicare beneficiaries, and the requirement to submit Medicare claims does not mean physicians or suppliers must accept assignment.”

Second, manufacturer product coding is generally voluntary unless mandated by the DME MAC. When coding is voluntary, the onus is on the supplier to make the best coding decision using existing codes and product characteristics. If it looks like a standard walker, acts like a standard walker and functions like a standard walker…then the claim should be filed using a standard walker HCPCS code (even if the vendor has not submitted the item for coding). However, a few items are subject to mandatory coding. Refer to the LCD for instructions and requirements for billing scenarios where mandatory coding is required by the MAC, but has not been secured by the manufacturer. Only in the event that the LCD provides for a statutory exclusion does claim filing become voluntary.