(Medicare Claims Processing Manual)

Use the following messages when denying claims due to invalid ABN upgrade information:   MSN  Detailed text  8.53:  This item or service was denied because the upgrade information was invalid.  N108:  This item/service was denied because the upgrade information was invalid.   120.1 - Providing Upgrades of DMEPOS Without Any Extra Charge  (Rev. 2993, Effective: ASC X12 -  01-01-12, ICD -10 - Upon Implementation of ICD -10; Implementation: ASC X12 -  08-25-14, ICD -10 - Upon Implementation of ICD -10)  Instead of using ABNs and charging beneficiaries for upgraded items, suppliers in certain circumstances may decide to furnish beneficiaries with upgraded equipment but charge the Medicare program and the beneficiary the same price they would charge for a n on-upgraded item.  The reason for this may be that a supplier prefers to carry only higher level models of medical equipment in order to reduce the costs of maintaining an inventory that includes a wide variety of different models and products.  Also, a supplier may be able to reduce its costs for replacement parts and repairs if it includes in its inventory only certain product lines.  The supplier may also be accommodating a physician order for an upgrade.   Policy   Suppliers are permitted to furnish upgraded DMEPOS items and to charge the same price to Medicare and the beneficiary that they would charge for a non- upgraded item.  This policy allows suppliers to furnish to beneficiaries, at no extra costs to the Medica re program or the beneficiary, a DMEPOS item that exceeds what the non -upgraded item that Medicare considers to be medically necessary.  Therefore, even though the beneficiary received an upgraded DMEPOS item, Medicares payment and the beneficiarys coins urance would be based on the Medicare allowed amount for a non-upgraded item that does not include features that exceed the beneficiarys medical needs.   Billing Instructions   When a supplier decides to furnish an upgraded DMEPOS item but to charge Medicare and the beneficiary for the non- upgraded item, the supplier must bill for the non-upgraded item rather than the item the supplier actually furnished.  The claim must include only the charge and HCPCS code for the non- upgraded item.  The HCPCS code for the non- upgraded item must be accompanied by the following modifier:   Modifier  Detailed Text  GL  Medically Unnecessary Upgrade Provided Instead of Non -upgraded Item, No Charge, No ABN   Suppliers must show the upgrade using the ASC X12 837 professional claim format, or in Item 19 of a paper Form CMS -1500 claim, or as an attachment.  The supplier must specify the make and model of the item actually furnished, that is, the upgraded item, and describe why this item is an upgrade   DME MACs are to pay based on Medicares payment amount for the non- upgraded item if it meets Medicares coverage and payment requirements.  A certificate of medical necessity, if applicable, must be completed for the HCPCS code that identifies the non-upgraded item but not for the upgraded item.   MSN Message:   For items accompanied with a GL modifier, use:   MSN  Detailed Text  8.51:  You are not liable for any additional charge as a result of receiving an upgraded item.   130 - Billing for Durable Medical Equipment (DME) and Orthotic/ Prosthetic Devices  (Rev. 2629, Issued: 01- 04-13, Effective: - 02-05-13, Implementation: 02- 05-13)  See 01 of this chapter  for definition of provider and supplier.   130.1 - Provider Billing for Prosthetic and Orthotic Devices  (Rev. 2629, Issued: 01- 04-13, Effective: - 02-05-13, Implementation: 02- 05-13)  See  01 of this chapter for definition of provider.   These items  consist  of all prosthetic  and orthotic  devices  excluding parenteral/enteral  nutritional  supplies  and equipment  and intraocular  lenses.   Prosthetics  and orthotic  devices  when provided during inpatient care are  included in  the Part A PPS rate unless  specified  as being  outside  the rate.  The link for information on services included and excluded from the SNF PPS is http://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/index.html .  The DME MAC  will not separately pay for items of DME provided to a beneficiary in a SNF.   Prosthetics, orthotics and supplies  that are considered  outside  the PPS rate may  be billed  by the  supplier in the case of a SNF or  hospital  to the A/B MAC (A) , or if furnished by a  qualified  outside  entity,  that entity  may  bill its  normal  contractor.   The SNFs,  hospitals, or  other  entities  that furnish  prosthetic  and/or  orthotic  devices  to their patients  for whom  Part A benefits  are not  payable (i.e., no Part  A entitlement or  benefits  exhausted)  may  bill for such  items,  assuming other  billing  requirements  are met.   NOTE:  Items  such  as catheters  and ostomy supplies  are excluded  from  the fee schedule when  billed  by HHAs  for patients  under  a plan  of care.  In  this situation,  HHAs  bill for these items  as supplies  under  revenue code 0270.  Effective  with items  furnished on or  after  January  1, 1994, the  fee schedules  for ostomy, tracheostomy, and  urological  supplies  are calculated  using the  same method  used to calculate the  purchase  fee schedules  for inexpensive  or other  routinely  purchased  DME.   HCPCS  codes  A4214, A4310 through A4330, A4338 through A4359, and  A5102 through A5114 are excluded  from  the fee schedule when  billed  by hospitals  along with  an ASC  service.  Hospitals  bill for these items  as supplies, under  revenue code  0272.  In addition, HCPCS  codes  A5119 through A5131 are excluded  from  the fee schedule  unless  they are submitted  with  ostomy  related  ASC  procedure  codes  44340 through 44346, 44380, 44382, 44388 through 44392, or  50953 through 50961.  In all other  circumstances,  including HHAs  billing  for patients  not under  a plan  of care,  SNFs,  CORFs,  OPTs,  and hospitals  bill these items  as prosthetics  and orthotics  under  code  0274, along with the relevant HCPCS code.   DME MACs  only -  For all states that have licensure/certification requirements for provision of prosthetics and/or orthotics, DME MACs  shall process claims for Prosthetics and Certain Custom -Fabricated Orthotics only when the following specialty codes are forwarded to the DME MACs  from the NSC.  The specialty codes are:    Medical Supply Company with Orthotics Personnel -  Specialty Code 51;    Medical Supply Company with Prosthetics Personnel -  Specialty Code 52;    Medical Supply Company with Orthotics and Prosthetics Personnel -  Specialty Code 53;    Orthotics Personnel -  Specialty Code 55;    Prosthetics Personnel -  Specialty Code 56;    Orthotics Personnel, Prosthetics Personnel and Pedorthists -  Specialty Code 57,   Physical Therapist -  Specialty Code 65;    Occupational Therapist -  Specialty Code 67;    Ocularist -  Specialty Code B5; and    All Physician Specialty Codes listed in this manual [IOM] Chapter 26, 10.8.2  These specialties shall be licensed or certified by the state when applicable.  These specialties shall bill for Medicare services when State law permits such entity to furnish a prosthetic or orthotic.   Claims billed by other specialty codes for prosthetics and certain custom -fabricated orthotics shall be denied.   130.2 - Billing for Inexpensive or Other Routinely Purchased DME  (Rev.4027; Issued: 04- 27-18; Effective: 10 -01-18; Implementation: 10 -01-18) This is equipment with a purchase price not exceeding $150, or equipment that the Secretary determines is acquired by purchase at least 75 percent of the time, or equipment that is an accessory used in conjunction with a nebulizer, aspirator, or ventilator s that are either continuous airway pressure devices or intermittent assist devices with continuous airway pressure devices. Effective October 1, 2015, this category also includes speech generating devices and accessories necessary for the effective use of  speech generating devices.  Suppliers and providers other than HHAs bill the DME MAC or, in the case of implanted DME only, the A/B MAC (B). HHAs bill the A/B MAC (HHH) or the DME MAC.   Effective for items and services furnished after January 1, 1991, Medicare DME does not include seat lift chairs. Only the seat lift mechanism is defined under Medicare as DME. Therefore, seat lift coverage is limited to the seat lift mechanism. If a seat lift chair is provided to a beneficiary, A/B MACs (A), and (HHH), and DME MACs pay only for the lift mechanism portion of the chair. Some lift mechanisms are equipped with a seat that is considered an integral part of the lift mechanism. A/B MACs (A) and ( HHH), and DME MACs do not pay for chairs (HCPCS code E0620) furnished on or after January 1, 1991. The appropriate HCPCS codes for seat lift mechanisms are E0627, E0628, and E0629.   For TENS, suppliers and providers other than HHAs bill the DME MAC. HHAs bill the A/B MAC             (HHH) using revenue code 0291 for the 2 -month rental period (see 30.1.2), billing each month as a separate line item and revenue code 0292 for the actual  purchase along with the appropriate HCPCS code.  130.3 - Billing for Items Requiring Frequent and Substantial Servicing  (Rev. 1, 10- 01-03) A3-3629, B3- 4107.8   These are items such as intermittent positive pressure breathing (IPPB) machines and ventilators, excluding ventilators that are either continuous airway pressure devices or intermittent assist devices with continuous airway pressure devices.   Suppliers and providers other than HHAs bill the DME MAC.  HHAs bill the A/B MAC (HHH).   130.4 - Billing for Certain Customized Items (Rev. 1, 10- 01-03) A3-3629, B3- 4107.8   Due to their unique nature (custom fabrication, etc.), certain customized DME cannot be grouped together for profiling purposes.  Claims for customized items that do not have specific HCPCS codes are coded as E1399 (miscellaneous DME).  This includes circu mstances where an item that has a HCPCS code is modified to the extent that neither the original terminology nor the terminology of another HCPCS code accurately describes the modified item.   Suppliers and providers other than HHAs bill the A/B MAC (B) or DME MAC.  HHAs bill their A/B MAC (HHH), using revenue code 0 292 along with the HCPCS.   130.5 - Billing for Capped Rental Items (Other Items of DME)  (Rev. 1, 10- 01-03) A3-3629, B3- 4107.8   These are DME items, other than oxygen and oxygen equipment, not covered by the above categories.  Suppliers and providers other than HHAs bill the DME MAC.  HHAs bill the A/B MACs (HHH).