In the ongoing battle for who decides what is medically necessary, doctors often order supplies in excess of Medicare coverage. Medicare considers any item that goes beyond the covered quantity an upgrade, even when prescribed. Suppliers caught in the middle have two choices when filling orders for excess supplies: charge the patient or give them away for free.
Billing Patients for Upgrades
In addition to billing Medicare for the covered supplies, suppliers can charge the beneficiary directly for excess supplies provided they obtain a properly executed Advance Beneficiary Notice (ABN) from the patient. The supplier then includes two lines on the Medicare claim:
For example, assume a doctor orders a non-insulin dependent diabetic patient to test two times per day. Because Medicare only covers one test per day, the patient needs twice the allowed testing strips over the same testing period. In this scenario, the patient needs four boxes of testing strips, not two, for a 90-day period. If the supplier cannot find coverage justification for the higher testing frequency, they can still dispense all four boxes, billing Medicare for two and charging the patient directly for the extra.
After obtaining an ABN from the patient, the supplier will include the following on the Medicare claim:
The GA modifier indicates the supplier has a signed ABN from the patient for excess quantities; this line must be reported on the claim first. The GK modifier identifies the covered items or quantities.
The patient pays the following amounts:
Suppliers cannot pass the contractual write-off amount for the covered supplies to the patient.
Free Upgrades
Alternatively, the supplier can provide the excess items or quantities at no additional charge to the beneficiary. Medicare does not require ABNs for free upgrades. The supplier includes a single line on the claim including the covered quantity of supplies and the GL modifier. The supplier also needs to include a claim narrative telling Medicare auditors how many units the patient actually received.
Using the same example as above, the supplier will include the following on the Medicare claim:
The GL modifier indicates the beneficiary received an upgrade ‑ a luxury item, or in this example, a more liberal supply.
In all cases, the proof of delivery must reflect the actual quantities delivered to the patient.
These upgrade protocols apply to virtually any supply HCPCS with a set limit on quantity (e.g., urological, surgical, ostomy, CPAP, and diabetic supplies). They do not apply to supply allowances which are based on units of time instead of quantity. Supply allowances cannot be limited by quantity when Medicare pays a fixed amount to cover whatever the patient needs for a given day or week or month as is the case for enteral administration kits, infusion sets, CGM supplies, and the like.
SOURCE LINKS
https://cgsmedicare.com/jc/pubs/news/2022/01/cope24725.html
Billing Patients for Upgrades
In addition to billing Medicare for the covered supplies, suppliers can charge the beneficiary directly for excess supplies provided they obtain a properly executed Advance Beneficiary Notice (ABN) from the patient. The supplier then includes two lines on the Medicare claim:
- Line 1 includes the total number of units provided and the GA modifier.
- Line 2 includes the covered number of units provided and the GK modifier.
For example, assume a doctor orders a non-insulin dependent diabetic patient to test two times per day. Because Medicare only covers one test per day, the patient needs twice the allowed testing strips over the same testing period. In this scenario, the patient needs four boxes of testing strips, not two, for a 90-day period. If the supplier cannot find coverage justification for the higher testing frequency, they can still dispense all four boxes, billing Medicare for two and charging the patient directly for the extra.
After obtaining an ABN from the patient, the supplier will include the following on the Medicare claim:
- Line 1 – A4253NUKSGA; QTY = 4.
- Line 2 – A4253NUKSGK; QTY = 2.
The GA modifier indicates the supplier has a signed ABN from the patient for excess quantities; this line must be reported on the claim first. The GK modifier identifies the covered items or quantities.
The patient pays the following amounts:
- 20 percent copay for the allowed units on line 2, and
- The difference between the usual and customary charge on line 1 and line 2.
Suppliers cannot pass the contractual write-off amount for the covered supplies to the patient.
Free Upgrades
Alternatively, the supplier can provide the excess items or quantities at no additional charge to the beneficiary. Medicare does not require ABNs for free upgrades. The supplier includes a single line on the claim including the covered quantity of supplies and the GL modifier. The supplier also needs to include a claim narrative telling Medicare auditors how many units the patient actually received.
Using the same example as above, the supplier will include the following on the Medicare claim:
- Line 1 - A4253NUKSGL; QTY = 2, and
- Claim narrative disclosing the patient received four boxes of strips.
The GL modifier indicates the beneficiary received an upgrade ‑ a luxury item, or in this example, a more liberal supply.
In all cases, the proof of delivery must reflect the actual quantities delivered to the patient.
These upgrade protocols apply to virtually any supply HCPCS with a set limit on quantity (e.g., urological, surgical, ostomy, CPAP, and diabetic supplies). They do not apply to supply allowances which are based on units of time instead of quantity. Supply allowances cannot be limited by quantity when Medicare pays a fixed amount to cover whatever the patient needs for a given day or week or month as is the case for enteral administration kits, infusion sets, CGM supplies, and the like.
SOURCE LINKS
https://cgsmedicare.com/jc/pubs/news/2022/01/cope24725.html
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