Billing Medicare for Substance Abuse Treatment

vpetrik 5 years ago in Payments/ERA Modules updated by Alyson Zurek, LICSW 5 years ago 8

I am trying to bill Medicare for Substance Abuse treatment for chemical dependency. We have a client who has Medicare as the primary provider and the secondary payer is Health Partners - PMAP. When I called Medicare to inquire about submitting a claim, I was told that I can't submit a claim to even get a rejection to send to the primary, because Medicare does not cover CD treatment. Has anyone else had this issue? Any help would be greatly appreciated

Victoria Petrik

We bill for outpatient CD services as well.  We first encountered this issue a number of years back and were told the same thing from Medicare - that they won't process or even issue a denial or rejection for CD claims because it's too costly for them to process claims as clients do not have CD benefits under Medicare.  I consulted with our CD Billing Specialist and she said that she has been able to bypass Medicare and bill the Pmap directly for the CD services.  She reported that the Pmaps have been processing as primary and have not requested the COB from Medicare.  I hope this helps.

I was going to suggest just billing the PMAP and don't even bother with Medicare. I think PMAPS and MA know when Medicare will not cover the service, whether it's the CPT code or provider. Glad it's working out for you.

Unfortunately, I have tried to bill to just the PMAP and they kick it back with a denial. When I called the PMAP (Health Partners) they said that I had to bill to Medicare first. But of course, when I called Medicare, I was told that they won't even issue or process a denial. I have tried to both process the PMAP as the primary and secondary. I am unsure as to what I should do at this point. 

We bill using the GY Modifier when billing a PMAP that is secondary to Medicare. This shows the PMAP that it is non-covered by Medicare.

For what type of service? Hopefully for Behavioral Heath, Same line as your treatment modifiers ?

How do you bill with a GY modifier? Our treatment codes that we use are TGU5, TFU5, and UDU5. Do you bill it out TG U5 GY? I have never billed with an additional modifier. Thank you!


Hi All, 

Here is a Knowledge Hub explaining how you can add the GY modifier for a specific client/payer scenario. 


If you need additional assistance, our support staff would be happy to help you through a support ticket.

This issue of billing for Substance Abuse Treatment has peaked my curiosity lately. There have been recent (this year) rule/statute changes called 245G that allow LADC's to treat on an outpatient basis apart from CD treatment centers. The way I am understanding this (open to hear if Im getting this wrong) is that an LADC can now get credentialed as an in-network provider with insurance companies, and that they do not have to have be licensed as a mental health provider as well (like with an LPCC). Does this mean that my mental health clinic would not have to become a state licensed CD clinic? Rather we could hire/contract a LADC to work with our clients who have substance use disorders and bill the codes directly to insurance companies? The only codes I am aware of that can be billed are: H2035 (individual outpatient) and H2035 HQ for outpatient group. What is the code for doing an Assessment?

My clinic is not currently a DHS licensed clinic, meaning I am just in private practice. Want to make sure I can pursue this option if that is the way the new 245G issue seems to read to me.