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January 18, 2022

Supplies – Use of Upgrade Modifiers

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 practitioner has signed an order for it. For supplies, if the quantity 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., coverage criteria in the Local Coverage Determination), that quantity can be considered an upgrade.

The Jurisdiction C Supplier Manual, Chapter 6PDF contains general information about the use of upgrade modifiers. If a supplier wants to collect from the beneficiary for the excess quantity of supplies, the supplier must obtain a properly completed Advance Beneficiary Notice (ABN). On the ABN claim lines, the supplier should

  • First bill the appropriate HCPCS code with a GA modifier and bill the units of service that describe the quantity of supplies that were provided
  • Then bill the same HCPCS code with a GK modifier and bill the units of service that describe the standard quantity of supplies that are covered based on the LCD

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 reasonable and 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

  1. the difference between the submitted charge for the GA claim line and the submitted charge for the GK claim line and
  2. 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 items.

If a supplier wants to provide the excess quantity of supplies without any additional charge to the beneficiary, the supplier does not need to obtain an ABN. 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 provided is not billed.

When using an upgrade modifier for excess quantities of supplies, the claim is not required to include 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. 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.

Examples:

Diabetic supplies:

The practitioner orders testing twice per day for a non-insulin treated beneficiary. The supplier provides 4 vials of test strips (50 in each) and 2 boxes of lancets (100 in each) as a 3-month supply. The supplier is unable to confirm that there is documentation in the 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

Urological supplies:

The practitioner orders clean technique intermittent self-catherization 5 times a day and PRN as needed. The supplier provides the allowed 200 catheters for a one-month supply justified by the medical record and the practitioner's order. The beneficiary wants 20 additional catheters a month (220 total) just in case. The supplier is unable to confirm there is documentation in the medical record that justifies the excess catheters requested by the beneficiary.

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 – A4351GA, 220 UOS
Line 2 – A4351KXGK,  200 UOS
Line 3 – A4332GA, 220 UOS
Line 4 – A4332KXGK, 200 UOS

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 – A4351KXGL, 200 UOS
Line 2 – A4332KXGL, 200 UOS

Refer to the Jurisdiction C Local Coverage Determinations and Policy Articles for additional information on coverage criteria, coding guidelines, and documentation requirements.

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