The best way to answer that question to look to some
guidance issued by the DMERC during a question and
answer session about the ABN form:
QUESTION What is the mechanism for upgrading from
one HCPCS code to another HCPCS code?
An
ABN for upgrade can be used when a beneficiary chooses a
higher level of service not prescribed by the treating
physician.
QUESTION Are all DMEPOS products eligible to be used
in upgrade situation (e.g., oxygen conserving devices)?
DMEPOS items that offer a component that the standard
item does not have are eligible for upgrade. Oxygen
conserving devices are included in the monthly oxygen
allowance.
QUESTION Is an upgrade from a manual wheelchair to a
power wheelchair or POV considered an appropriate use of
an ABN with upgrade?
Yes.
The beneficiary may upgrade to a power wheelchair or POV
as long as the treating physician does not oppose the
use.
QUESTION How is an upgrade within a HCPCS code
accomplished and when is it appropriate? How does
medical necessity play a role in this? We have four
examples of questions concerning this:
a. A
"traditional" CPAP is tolerated well by the Medicare
patient but he wants an "auto-CPAP" device because his
daughter is an RRT and he is aware of the latest
technology. The physician sees no harm in the patient
using an auto-CPAP. Can the patient pay the difference
between the regular CPAP and the auto-CPAP price?
b.
The Medicare patient wants a nasal mask and a nasal-oral
mask (which costs more) in order to rotate masks but,
there is no medical necessity for the nasal-oral mask,
the patient just wants one. Can the patient pay for the
additional mask?
c.
The least costly nasal mask is working fine but the
Medicare patient heard about the gel mask and wants one.
Can the supplier upgrade the patient and charge them
more than the least costly mask since the new technology
mask costs more?
d.
The Medicare patient prefers the high tech volume
ventilator that provides pressure support ventilation as
well but a PLV ventilator meets medical necessity. Can
the patient be asked to pay the difference between the
"traditional" volume ventilator and the new high
technology volume ventilator?
a. -
d. Per CMS, ABNs may not be used to charge beneficiaries
more for “higher quality” items when there is not a
distinguishable excess component of the items. An
upgrade can be provided if the item provides an excess
component that the standard item does not have. An
excess component, with respect to items that are more
expensive, refers to increased charges attributable to
furnishing something that is clearly more extensive –
that is more in number, more frequent, for a longer
period of time, or with added features. A deluxe or
aesthetic feature of an upgraded item is an excess
component. It does not suffice merely to claim that an
item is “better” or “higher quality.”
QUESTION What is the upgrade amount that gets billed
to the beneficiary – is it the difference between the
allowed amount and the retail charge for the upgrade
(plus co-payments, etc.), or is it the difference
between the retail price for the standard item and the
upgrade (plus co-payments based on the allowed amount)?
The
amount suppliers may collect from the beneficiary is the
difference between the submitted charge for the upgrade
item and the submitted charge for the standard item
ordered by the physician plus any co-pay and deductible.
QUESTION The CMS document directs carriers to
require charges for the standard/upgrade on the
HCFA-1500 form, but is not clear about how to handle the
transaction from the beneficiary end. It is also not
clear what a standard item is. Most suppliers choose an
item that is standard for its business, but those items
vary by supplier and there is no statutory or regulatory
definition of what is “standard.” A key here is a
provider knowing what needs to be programmed into the
supplier’s computer system when producing the HCFA-1500
form.
Standard equipment equals equipment prescribed by the
physician. You should follow the same guidelines you
used prior to ABNs for upgrades for determining what is
standard equipment.
QUESTION If the beneficiary is found to be not
liable for some reason or does not pay as agreed, can
the provider pick up the equipment?
If
the beneficiary signs the ABN for upgrade accepting
liability, s/he is responsible for payment. Failure to
make payment can result in the supplier picking up the
upgrade item and providing the non-upgraded item
prescribed by the treating physician.
QUESTION For beneficiaries who routinely use more
supplies than permitted by the frequency limits (e.g.
urologicals), must the supplier get an ABN signed every
time the beneficiary gets supplies or only when they
exceed the monthly supply limit?
No.
Once obtained, the ABN is valid for future services for
that item.
QUESTION Can a supplier provide an upgrade covered
item without billing the patient? How does a supplier
submit this type of claim to Medicare? Does this
scenario change for a non-covered item?
Suppliers may provide free upgrades to beneficiaries.
For example, some suppliers only stock K0004
wheelchairs. They may file a claim for the medically
necessary item (K0001) with the GL modifier (e.g.,
K0001RRKHGL). The item that was actually provided to the
beneficiary must be described in Item 19 on the
HCFA-1500 claim form.
ABNs
do not apply to non-covered items.
QUESTION Regarding the upgrade option on a capped
rental item: Can the provider accept the difference in
the amount for the full capped rental period in the
first month or do they have to bill the patient each
month for the difference?
Suppliers must file claims for the upgraded item
according to the billing instructions for the standard
item prescribed by the treating physician. For capped
rental items, you should bill on a monthly basis.
QUESTION If a supplier provides the patient with the
upgrade, does he submit the claim using the upgrade
piece of equipment HCPCS code or does he file using the
HCPCS code for equipment that the patient qualifies for?
Both
items must be listed on the HCFA-1500 claim form
indicating the submitted charges for each item. The
upgrade item is filed on line one with the GA modifier
and the standard item is filed on line two with the GK
modifier. The following is an example:
Upgrade item K0004RRKHGA $100.00 (submitted charge)
Prescribed item K0001RRKHGK $ 50.00 (submitted charge)
Claim total $150.00
QUESTION Are the charges the difference between the
upgrade equipment and the allowed amount or should a
provider file the retail amount for the equipment that
is ordered by the physician?
The
amount suppliers may collect from the beneficiary is the
difference between the submitted charge for the upgrade
item and the submitted charge for the standard item
ordered by the physician plus any co-pay and deductible.
QUESTION Is the submitted price on the upgrade item
our customary charge or the Medicare allowed amount?
The
submitted price is your customary charge for the upgrade
item.
QUESTION Is a provider required to bill the upgrade
as a non-assigned claim and the ordered equipment as an
assigned claim?
Assignment is on a claim by claim basis and both items
must be listed on the same HCFA-1500 claim form
indicating the submitted charges for each item. The
upgrade item is filed on line one with the GA modifier
and the standard item is filed on line two with the GK
modifier.
QUESTION If the supplier has provided an upgrade to
a beneficiary (prior to the new policy being released by
the DMERC) is the supplier required to include the
modifiers with the claims?
If
the beneficiary chose an upgrade item, it must be
indicated to Medicare. If an ABN for upgrade was signed
and claims were previously filed without reflecting the
upgrade, you should request a review to have the claim
correctly indicate an upgrade was provided. We recommend
sending a copy of the ABN with your review request.
Subsequent claims must be filed accurately reflecting
the upgrade and using the appropriate modifiers.
QUESTION What equipment is required to be on the CMN?
The equipment the patient wants or the equipment they
qualify for?
a. A
CMN is required for the item ordered by the physician.
b.
The HCPCS code of the ordered item must be included in
Section A of the CMN.
c. A description of the ordered item, retail amount and
Medicare allowable amount
must
be listed in Section C of the CMN
You can download the ABN
form by clicking here (pdf file)
