By Carrie Nienberg, RN, Director of Clinical Operations
Effective immediately, you as a supplier may provide and bill E0467, multi-function ventilator, as an upgrade when the beneficiary only qualifies for the ventilator. Until now, the beneficiary had to meet coverage requirements for the ventilator and at least one of the following: oxygen concentrator, cough stimulator, suction pump or nebulizer.
Following the upgrade guidelines, you would bill according to whether you provide the upgrade and expect no additional payment, are providing the upgrade expecting beneficiary payment, or beneficiary requests the upgrade, but you expect no additional payment.
The supplier will bill for the above scenarios as follows:
- Supplier provides the upgrade at no additional charge to the beneficiary:
- Bill E0465/E0466 with the GL modifier (medically unnecessary upgrade provided instead of standard item, no charge, no ABN)
- Supplier provides the upgrade and charges the beneficiary for the upgrade:
- Bill E0467 with GA modifier (waiver of liability statement on file) on line one, bill E0465/E0466 with GK modifier (actual item/service ordered by physician, item associated with GA or GZ modifier) on line two
- You must obtain a properly executed ABN
- Beneficiary requests the upgrade, but supplier will not charge for additional payment:
- Bill E0467 with GZ modifier (item or service expected to be denied as not reasonable or necessary) on line one, bill E0465/E0466 with GK modifier (actual item/service ordered by physician, item associated with GA or GZ modifier) on line two
CMS is suspending claims editing for multi-function ventilators when there are claims for separate devices in history that have not met their reasonable useful lifetime, effectively immediately.
Click HERE to review the CMS guidance.