Standardized claim forms, whether electronic or paper, are great for communicating lots of information efficiently. But what if a billable transaction isn’t … you know … standard?
Enter the narrative.
The narrative, otherwise known as the NTE 2400-line item note for electronic claims, allows suppliers to transmit special instructions to the applicable payer for each service or line item. With a limit of 80 characters, however, narratives make tweets look like epic novels.
Because space is limited, suppliers must be purposeful with every letter. To assist suppliers with crafting clear and concise narratives, CGS posted a list of over 90 common abbreviations to use when populating narratives. Noridian also has a shorter list of narrative abbreviations.
This article is the first in our series exploring the role of the narrative in common scenarios such as:
But first, let’s consider a few general situations that require narratives to avoid denials.
More Than Four Modifiers
Claim forms have space for a maximum of four modifiers, but sometimes circumstances require more. Billers can use the narrative field to work around the four-modifier limitation, but they must first determine if an upgrade is part of the billable transaction:
No Upgrade (99) Sample Narrative
Normally, a hospital bed rental in the first month requires three modifiers. If, however, the same bed replaces existing equipment after five years and the patient is a traveling beneficiary who normally resides in a competitive bid area, five modifiers are required. Since the billable transaction is unrelated to an upgrade, the claim and narrative should read:
Enter the narrative.
The narrative, otherwise known as the NTE 2400-line item note for electronic claims, allows suppliers to transmit special instructions to the applicable payer for each service or line item. With a limit of 80 characters, however, narratives make tweets look like epic novels.
Because space is limited, suppliers must be purposeful with every letter. To assist suppliers with crafting clear and concise narratives, CGS posted a list of over 90 common abbreviations to use when populating narratives. Noridian also has a shorter list of narrative abbreviations.
This article is the first in our series exploring the role of the narrative in common scenarios such as:
- O2 restarts.
- Breaks in service and need.
- Equipment replacement.
- Repairs.
But first, let’s consider a few general situations that require narratives to avoid denials.
More Than Four Modifiers
Claim forms have space for a maximum of four modifiers, but sometimes circumstances require more. Billers can use the narrative field to work around the four-modifier limitation, but they must first determine if an upgrade is part of the billable transaction:
- If no upgrade is involved, enter the first three applicable modifiers and then 99 in the final modifier spot.
- If an upgrade is involved, enter the first three applicable modifiers and then KB in the final modifier spot.
No Upgrade (99) Sample Narrative
Normally, a hospital bed rental in the first month requires three modifiers. If, however, the same bed replaces existing equipment after five years and the patient is a traveling beneficiary who normally resides in a competitive bid area, five modifiers are required. Since the billable transaction is unrelated to an upgrade, the claim and narrative should read:
Upgrade Overflow (KB) Sample Narrative
If the same scenario above involved an upgrade instead of a replacement, the supplier would bill as follows:
If the same scenario above involved an upgrade instead of a replacement, the supplier would bill as follows:
Statutorily Non-Covered Items Billed With a GY Modifier
When beneficiaries use products for purposes that are not specifically discussed in the statute, the service is not covered. In such cases, the LCD calls for the use of the GY modifier.
Sometimes, otherwise eligible equipment is not covered for certain situations and uses. Suppliers must review the section “Non-Medical Necessity Coverage And Payment Rules” in the related policy article to understand when specific uses render the service not covered. Examples include:
When the use case is excluded by statute, suppliers must append the GY modifier to the claim and include a narrative identifying the equipment and explaining the circumstances that cause the item to be non-covered. By default, claims with a GY will deny for missing information if the supplier does not attach a narrative.
Statutorily Non-Covered Item Sample Narrative (31 characters)
When beneficiaries use products for purposes that are not specifically discussed in the statute, the service is not covered. In such cases, the LCD calls for the use of the GY modifier.
Sometimes, otherwise eligible equipment is not covered for certain situations and uses. Suppliers must review the section “Non-Medical Necessity Coverage And Payment Rules” in the related policy article to understand when specific uses render the service not covered. Examples include:
- Commodes used as raised toilet seats over a functioning toilet.
- Wheelchairs used exclusively outside the home.
- Surgical dressings used for wound cleansing.
- Therapeutic shoes used for non-diabetics.
- Catheters used to manage urinary tract infections without incontinence.
When the use case is excluded by statute, suppliers must append the GY modifier to the claim and include a narrative identifying the equipment and explaining the circumstances that cause the item to be non-covered. By default, claims with a GY will deny for missing information if the supplier does not attach a narrative.
Statutorily Non-Covered Item Sample Narrative (31 characters)
Free Upgrades Billed With a GK Modifier
Free upgrades are scenarios where suppliers choose to provide an upgraded item without any additional charge to the beneficiary. Suppliers do this when it is more economical to purchase higher-level items in larger volumes and then use the premium item to meet the needs of substantially all beneficiaries. For example, some suppliers offer semi-electric beds in lieu of variable height beds or fixed height beds.
When suppliers provide the upgraded item at no additional charge to the beneficiary, the supplier must bill the lesser, medically necessary item with a GL modifier. Additionally, the narrative must document the make and model of the upgrade, HCPCS of the upgraded equipment, and the features that make it an upgrade. By default, the payer will deny claims that do not have a narrative to explain what item(s) the beneficiary actually received.
Free Upgrade Sample Narrative (56 characters)
Free upgrades are scenarios where suppliers choose to provide an upgraded item without any additional charge to the beneficiary. Suppliers do this when it is more economical to purchase higher-level items in larger volumes and then use the premium item to meet the needs of substantially all beneficiaries. For example, some suppliers offer semi-electric beds in lieu of variable height beds or fixed height beds.
When suppliers provide the upgraded item at no additional charge to the beneficiary, the supplier must bill the lesser, medically necessary item with a GL modifier. Additionally, the narrative must document the make and model of the upgrade, HCPCS of the upgraded equipment, and the features that make it an upgrade. By default, the payer will deny claims that do not have a narrative to explain what item(s) the beneficiary actually received.
Free Upgrade Sample Narrative (56 characters)
Supplies Used With Patient-Owned Base Equipment
When beneficiaries change insurance, use donated equipment, or purchase items privately, the insurance has no record of the base equipment. By default, the payer will deny claims for accessories when they have no history of the base equipment. Suppliers must use the narrative to establish history.
The narrative should include the:
When beneficiaries change insurance, use donated equipment, or purchase items privately, the insurance has no record of the base equipment. By default, the payer will deny claims for accessories when they have no history of the base equipment. Suppliers must use the narrative to establish history.
The narrative should include the:
- Justification for the narrative.
- Designation of patient-owned base equipment.
- HCPCS and description of the base item.
- Approximate date of when the original equipment was delivered so the payer can calculate a reasonable useful lifetime for the base equipment.
Miscellaneous HCPCS
Payers mandate a narrative when suppliers bill for miscellaneous codes. In Medicare publications, miscellaneous codes are sometimes referred to as “not otherwise classified (NOC)” or “not otherwise specified.” Miscellaneous codes are effectively blank slates with no specific definition of their own, so payers need a narrative to determine what is being billed, why it is needed, and how to price it. By default, the payer will reject miscellaneous claims without a narrative.
The narrative must contain a description of the item, manufacturer, part/model number, HCPCS of the related base item, and a retail price. In the sample narrative below, the supplier is billing the miscellaneous HCPCS K0108 for knee supports attached to a power wheelchair at a rate of $300.
Miscellaneous HCPCS Sample Narrative (57 characters)
Payers mandate a narrative when suppliers bill for miscellaneous codes. In Medicare publications, miscellaneous codes are sometimes referred to as “not otherwise classified (NOC)” or “not otherwise specified.” Miscellaneous codes are effectively blank slates with no specific definition of their own, so payers need a narrative to determine what is being billed, why it is needed, and how to price it. By default, the payer will reject miscellaneous claims without a narrative.
The narrative must contain a description of the item, manufacturer, part/model number, HCPCS of the related base item, and a retail price. In the sample narrative below, the supplier is billing the miscellaneous HCPCS K0108 for knee supports attached to a power wheelchair at a rate of $300.
Miscellaneous HCPCS Sample Narrative (57 characters)
In addition to the above elements, miscellaneous surgical dressing codes require details related to the pad size for wound covers and the number of ounces or grams in each tube/packet for wound fillers. These additional elements apply to miscellaneous HCPCS A4649, A6261, A6262, and A6512.
When off-the-shelf or custom molded shoes are substantially modified, the narrative for the miscellaneous modification must also provide a justification for the modification. This additional element applies to miscellaneous HCPCS A5507.
Narratives act as a supplier’s advocate at the time of claim processing. Use them to make a convincing argument.
Next time, we’ll discuss narratives for restarting oxygen equipment, breaks in service, and breaks in need.
When off-the-shelf or custom molded shoes are substantially modified, the narrative for the miscellaneous modification must also provide a justification for the modification. This additional element applies to miscellaneous HCPCS A5507.
Narratives act as a supplier’s advocate at the time of claim processing. Use them to make a convincing argument.
Next time, we’ll discuss narratives for restarting oxygen equipment, breaks in service, and breaks in need.
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