By Carrie Nienberg, Clinical Director at The van Halem Group
Did you know you could use the upgrade modifiers when billing for supplies provided to a beneficiary that exceeds the allowed amount specified in the Local Coverage Determinations (LCD)?
For example, the urological supplies LCD allows for one catheter kit (A4314) per month. In the event you receive an order for two kits and the documentation provided in the patient’s medical record only supports the need for one kit, you can bill Medicare for one and then the second can be considered an upgrade.
If you want to collect the money from the beneficiary for the additional kit, you need to obtain a valid Advance Beneficiary Notice (ABN) and then bill with the appropriate liability modifiers: GA, GK or GL.
- GA: Waiver of liability statement on file (Fully executed ABN obtained)
- GK: Reasonable and necessary item/service associated with GA or GZ modifier.
- GL: Medically unnecessary upgrade provided, no charge, no ABN.
In the example above, when billing the claim to Medicare, the first line would be A4314 GA, 2 units of service since that is the quantity you provided. On the second claim line, you would add A4314 KXGK, 1 unit of service, which is the quantity allowed based on the LCD.
If you want to provide the additional catheter kit withhout collecting payment and no ABN is obtained, you would bill A4314 KXGL, 1 unit of service.
For additional information, refer to the CGS DME MAC website.