Article Detail - JD DME

Original Effective Date: 11/11/2010
Revision Effective Date: 11/01/2013

(Note: This article is a revision to an article published in November 2010. The revised language is underlined.)

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. For glucose monitor supplies, if the quantity of test strips and lancets that is provided exceeds the standard amount specified in the LCD and if the supplier does not have information indicating that all of the criteria for coverage of the excess quantities have been met (i.e., criteria [a]-[f] in the Glucose Monitors Local Coverage Determination), that quantity can be considered an upgrade.

General information about the use of upgrade modifiers is found in the Jurisdiction D Supplier Manual, Chapter 6. Applying this to test strips and lancets, if a supplier wants to collect from the beneficiary for the excess quantity of supplies, a properly completed ABN must be obtained. If an ABN is obtained, on one claim line the supplier bills the appropriate HCPCS code with a GA modifier and bills the units of service that describe the quantity of supplies that were provided. On the next claim line, the supplier bills the same HCPCS code with a GK modifier and bills the units of service that describe the standard quantity of supplies that are covered based on the LCD. (Note: The codes must be billed in this specific order on the same 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. (Note: When using the upgrade modifiers, the submitted charge for the upgrade [GA modifier line] – i.e., the quantity of supplies that were provided – may be the supplier's "usual and customary" fee for the upgraded item.)

If a supplier wants to provide the excess quantity of supplies without any additional charge to the beneficiary, then no ABN is obtained. The supplier bills the HCPCS code with a GL modifier and bills the units of service that describe the quantity of supplies that are covered based on the LCD. The quantity of supplies that is provided is not billed.

When using an upgrade modifier for excess quantities of test strips, suppliers are not required to include on the claim the brand name of the product(s) or an explanation for why it is considered an upgrade.

Codes with a GK or GL modifier will continue through the usual claims processing. For test strips and lancets, if the units of service on the GK/GL claim line are within the policy guidelines, then that claim line will not hit an edit which is focused on individual claims lines with excess units of service. If no other edits hit the claim line, payment will be made based on the units of service billed for the code with the GK or GL modifier.

Example:

The physician orders testing twice per day for a non-insulin treated patient. The supplier provides 4 vials of test strips (50 in each) and 2 boxes of lancets (100 in each) as a three month supply. The supplier is unable to confirm that there is documentation in the patient's medical record that justifies the need for twice per day testing and/or documentation (e.g., beneficiary log) that the beneficiary is testing at that frequency.

If the supplier wants to collect payment for the excess quantity of supplies from the beneficiary and obtains a properly completed ABN, the claim is billed as:

• Line 1 – A4253NUKSGA, 4 UOS, 90 day date span
• Line 2 – A4253NUKSGK, 2 UOS, 90 day date span
• Line 3 – A4259NUKSGA, 2 UOS, 90 day date span
• Line 4 – A4259NUKSGK, 1 UOS, 90 day date span

If the supplier does not want to collect payment for the excess quantity from the beneficiary, no ABN is obtained and the supplier bills:

• Line 1 – A4253NUKSGL, 2 UOS, 90 day date span
• Line 2 – A4259NUKSGL, 1 UOS, 90 day date span

Refer to the Glucose Monitors Local Coverage Determination and Policy Article for additional information on coverage criteria, coding guidelines, and documentation requirements.