Upgrades - JA DME

An upgrade is defined as an item that goes beyond what is medically necessary under Medicare's coverage requirements. An item can be considered an upgrade even if the physician has signed an order for it. Upgrades that do not meet the coverage criteria in the applicable Local Coverage Determination (LCD) will not be paid in full. The supplier can still obtain partial payment at the time of initial determination if the claim is billed using one of the upgrade modifiers, GK or GL. The descriptions of the modifiers are:

• GK - Reasonable and necessary item/service associated with a GA or GZ modifier
• GL - Medically unnecessary upgrade provided instead of non-upgraded item, no charge, no Advance Beneficiary Notice of Noncoverage (ABN)

1. If a supplier wants to collect from the beneficiary for the upgraded item provided, a properly completed ABN must be obtained. When an ABN is obtained:
   • Claim line one is billed with a GA modifier and the HCPCS code that describes the item that was provided.
   • The next claim line is billed with the GK modifier and the HCPCS code that describes the item that is covered based on the LCD. (Note: The codes must be billed in this specific order on the claim.)
   In this situation, the claim line with the GA modifier will be denied as not medically necessary with a "patient responsibility" (PR) message and the claim line with the GK modifier will continue through the usual claims processing. The beneficiary liability will be the sum of (a) the difference between the submitted charge for the GA claim line and the submitted charge for the GK claim line and (b) the deductible and co-insurance that relate to the allowed charge for the GK claim line. The supplier may charge their "usual and customary" fee for the upgraded item that is provided.
   Example one:
   
2. If a supplier wants to provide the upgraded item without any additional charge to the beneficiary, then no ABN needs to be obtained. When the supplier decides to provide the upgraded item at no additional charge to the beneficiary or if a physician ordered the upgraded item and the supplier decides to provide it at no additional charge to the beneficiary:
   • Supplier bills with a GL modifier and the HCPCS code that describes the item that is covered based on the LCD.
     • Add a narrative to the claim line with the HCPCS code and or description of the upgraded item provided
   In this situation, the supplier does not bill the HCPCS code that describes the item that was provided.
   Example two:
   
3. If the request for the upgraded item is from the beneficiary and the supplier decides to provide it at no additional charge, no ABN needs to be obtained.
   • On the first claim line, the supplier bills with a GZ modifier and the HCPCS code that describes the item that was provided.
   • On the next claim line, the supplier bills with a GK modifier the HCPCS code that describes the item that is covered based on the LCD. (Note: The codes must be billed in this specific order on the claim.)
   Example three:
   

• Footnotes: GK or GL is added to HCPCS code for item that meets Medicare coverage requirements.
• When GK is used, GA or GZ is added to HCPCS code for item that is provided.
• R&N = Reasonable and necessary

Suppliers are reminded that if there is a requirement in a specific policy to use a KX modifier to indicate that an item meets coverage criteria, then it is used in addition to the GK or GL modifier. Codes with a GK or GL modifier will continue through the usual claims processing. Other edits may cause the GK/GL claim line to be denied. However, if no other edits are involved, payment will be made based on the fee schedule for the code with the GK or GL modifier.

When a fully electronic hospital bed is provided, this is always an upgrade situation and should be billed appropriately as per the above guidelines.

Reminders