Skip over navigation

Upgrades

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. When suppliers know that an item will not be paid in full because it does not meet the coverage criteria stated in Local Coverage Determination (LCD), 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)

If a supplier wants to collect from the beneficiary for the upgraded item provided, a properly completed ABN must be obtained. If an ABN is obtained, on one claim line the supplier bills with a GA modifier 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.) 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.

If a supplier wants to provide the upgraded item without any additional charge to the beneficiary, then no ABN is obtained. If it is the supplier's decision to provide the upgraded item at no additional charge to the beneficiary or if physician ordered the upgraded item and the supplier decides to provide it at no additional charge to the beneficiary, the supplier bills with a GL modifier the HCPCS code that describes the item that is covered based on the LCD. In this situation, the supplier does not bill the HCPCS code that describes the item that was provided.

If the request for the upgraded item is from the beneficiary and the supplier decides to provide it at no additional charge, no ABN is obtained. On one claim line the supplier bills with a GZ modifier 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.)

Upgrade Scenario ABN Required Beneficiary Pays for Upgrade Required Modifier(s) DMAC Payment Item Listed on DWO or WOPD
Physician Orders Upgrade
Supplier provides upgrade free of charge to beneficiary
No GL R&N Item Only (GL Line) Upgrade Item
Physician Orders Upgrade
Supplier bills beneficiary for upgrade
Yes GA/GK R&N Item Only (GK Line) Upgrade Item
Patient Requests Upgrade
Supplier provides upgrade free of charge to beneficiary
No GZ/GK R&N Item Only (GK Line) R&N Item Only
Patient Requests Upgrade
Supplier bills beneficiary for upgrade
Yes GA/GK R&N Item Only (GK Line) R&N Item Only
Supplier Provides Upgrade for Supplier Convenience
Supplier provides upgrade free of charge to beneficiary
No GL R&N Item Only  (GL Line) R&N Item Only

  • 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.

Reminders

Topic Reminder
Proof of Delivery (POD) Must reflect what the beneficiary received from the supplier
GL Modifier Narrative required to show what was received by the beneficiary

 

Last Updated Apr 26, 2017