How to bill upgrades to Medica...

Billing Upgrades to Medicare Patients on DME

Medical upgrades under Medicare’s coverage requirements are items that have gone beyond what is necessary medically but an order for the items have been signed by a doctor, for example, an electronic hospital bed. Billing upgrades to Medicare patients on DME to Local Coverage Determination (LCD) that do not meet the criteria for coverage will not be paid in full amount, and therefore DME billing to Medicare patients for upgrades follow appropriate DME billing guidelines. They are certain upgrade modifiers such as GK, or GL that must be used to continue through the usual processing when billing DME claims for the upgrade items.

Modifiers such as GK, or GL is added to HCPCS code for upgrade items to Medicare patients on DME that meets Medicare coverage requirements. If at the initial determination the claims of the upgrades are billed using any of the upgrade modifiers, the suppliers of the upgrades can receive partial payment for the upgrades. GK upgrade modifiers are for reasonable and necessary items or, services associated with GZ or GA modifier, while GL upgrade modifiers are for unnecessary upgrades provided instead of non-upgraded items, no Advance Beneficiary Notice of Non-coverage (ABN), and no charges.

If the supplier charges their usual and customary fees for the upgrade items provided to the Medicare patients, a completed Advance Beneficiary Notice of Non-coverage (ABN) must be obtained by the supplier in other to make DME claims for the upgrade items. The claims for the upgrade items on DME have specific order in which the HCPCS codes must be billed. The supplier will bill the first claim line with the GA modifier and the HCPCS code that is provided that describes the upgrade items on DME. The supplier will bill the second claim line with the GK modifier and the HCPCS code is covered that describes the upgrade items on DME based on LCD.

If the claims for the upgrade items for the Medicare patients follow the order, the first claim line billed with the GA modifier will be denied as not necessary with a patient responsibility (PR) on it while the second claim line billed with the GK modifier will continue the processing for the claims. The Medicare patients liabilities will be the total sum up of the difference between the submitted charge for the first claim line with the GA modifier, the submitted the charge for the second claim line the GK modifier, and the deductible and co-insurance that relates to the allowed charges for the second claim line with the GK modifier.

However, if the supplier decides to provide the upgrade items to Medicare care patients without any additional charge, then no ABN needs to be obtained. The supplier will bill the claims for the upgrade items with the GL modifier and the HCPCS code that is covered that describes the upgrade items based on the LCD. The supplier will not bill the claims for the upgrade items on DME with the HCPCS code that was provided that describes the upgrade items on DME.

The claims for the upgrade items on DME have specific order which the HCPCS codes must be billed. On the first claim line, the supplier will bill the claims for the upgrade items with the GZ modifier and the HCPCS code that was provided that describes the upgrade items, while on the second claim line, the supplier will bill the claims for the upgrade items with the GK modifier the HCPCS code that is covered that describes the upgrade items based on LCD.

Payments for the DME billing to Medicare patients will be made to the supplier if there are no other edits involved, based on the fee schedule for the HCPCS code for upgrade items that meet Medicare coverage requirements with the GK or GL modifier.