(Medicare Claims Processing Manual)

3. A facility may not, through a stratagem of relying upon a supplier to furnish such items, improperly shift its costs for furnishing medically necessary items to a beneficiary who is a resident in the facility to Medicare Part B.   Nevertheless, beginning two days before the beneficiary's discharge, a facility may take reasonable actions to permit a supplier to fit or train the beneficiary with the medically necessary item that is for subsequent use in the beneficiary's home.  These actions may include the substitution of the supplier -furnished item, in whole or in part, for the facility-furnished item during the beneficiary's last two inpatient days provided the substitution is both reasonable and necessary for fitting or training and the item is intended for subsequent use at the beneficiary's home.   4. For prosthetic and orthotic (P&O) items, the above restrictions apply to residents in a covered Part A stay.  For DME, the above restrictions apply in a covered Part A or a Part B stay.   110.4 - Frequency of Claims for Repetitive Services (All Providers and Suppliers)  (Rev. 1, 10- 01-03)  HHAs include DMEPOS on bill types 32x or33x with home health visits bill at the freqency required for the home health.  See Chapter 10 for home health billing requirements.   Other providers and suppliers, including home health agencies billing the A/B MAC (HHH) on bill type 34x, submit claims on a monthly basis unless  another policy that allows billing at a different frequency applies.  For example suppliers may bill for more than one month's diabetic test strips.  Claims are submitted in sequence where there are cases of known continuous periods of service over an extended period (e.g., capped rental equipment or therapies).  When there is a break in service (e.g. interruption of capped rental as the result of an ex tensive inpatient stay), suppliers should continue sequential billing when the services resume.   The purpose of these requirements is to avoid CMS operational expenditures, and at the same time simplify the review process   110.5 - DME MACs Only - Appeals of Duplicate Claims  (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)  The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) must afford appeal rights for the initial determination of an item or service only, unless the supplier is appealing whether or not the denied item is actually a duplicate.  If a claim is denied as a duplicate, the DME MACs must not afford appeal rights based on coverage, medical necessity, pricing, or any basis on which the supplier can otherwise appeal.  The DME MAC may only afford appeal rights on claims denied as duplicates if the supplier is appealing because the claim is not, in fact, a duplicate.  If a supplier appeals a denied duplicate claim on the basis that the claim is not, in fact a duplicate, the DME MAC shall adjudicate the claim in accordance with all other Medicare rules and regulations.  The DME MACs must use the following Medicare Summary Notice (MSN) and ASC X12 835 remittance messages when denying duplicate claims:    MSN 7.3 -  This service/item is a duplicate of a previously processed service.  No appeal rights are attached to the denial of this service except for the issue as to whether the service is a duplicate.  Disregard the appeals information on this notice unle ss you are appealing whether the service is a duplicate.    Spanish -  Este servicio/artculo es un duplicado de otro servicio procesado previamente.  No tiene derechos de apelacin de este servicio, excepto si cuestiona que este servicio es un duplicado.  Haga casa omiso a la informacin sobre apelaciones en esta n otification, en relacin a sus derechos de apelacin, a menos que este apelando si el servicio fue duplicado.   Claim adjustment r eason code 18: - Duplicate claim/service   Remittance advice remark code N111 -  This service was included in a claim that was previously billed and adjudicated.  No appeal rights attached except with regard to whether the service/item is a duplicate.   120 - DME MACs - Billing Procedures Related To Advanced Beneficiary Notice (ABN) Upgrades  (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)  This section provides the DME MACs billing instructions regarding the use of ABNs and claims modifiers for upgrades for items of DMEPOS.  Federal Regulations at 42 CFR 411.408 and Chapter 30 of this manual establishes the basis for a supplier to issue an ABN to a beneficiary.  The purpose of the ABN is to inform a Medicare beneficiary, before he or she receives an item that Medicare will probably not pay for that particular item on that particular occasion.  The ABN allows the beneficiary to make an informed consumer decision on whether to accept an item for which he or she may have to pay out of pocket or through supplementary insurance.   Under existing policy, suppliers may collect from a beneficiary a payment amount greater than Medicares allowed payment amount if the beneficiary, by signing an ABN, agrees to pay extra for a DMEPOS item because the beneficiary prefers an item with featur es or upgrades that are not medically necessary.  This policy applies to both assigned and unassigned claims.  When a beneficiary does not sign an ABN, a supplier that accepts assignment cannot hold the beneficiary liable for the cost of medically unnecess ary equipment or upgrades unless there is other acceptable evidence that the beneficiary knew or could reasonably have been expected to know that Medicare would not pay for the medically unnecessary equipment or upgrades.  With respect to unassigned claims , a signed ABN is necessary to hold the beneficiary liable.   The instructions in this section apply to situations where the ABN is being used for upgrades and applies to both assigned and unassigned claims.  An upgrade is an item with features that go beyond what is medically necessary.  An upgrade may include an excess component.  An excess component may be an item feature or service, which is in addition to, or is more extensive and/or more expensive than the item that is reasonable and necessary under Medicares coverage requirements.  When a DMEPOS supplier knows  or believes that the DMEPOS item does or may not meet Medicares reasonable and necessary rules under specific circumstances, it is the responsibility of the supplier to notify the beneficiary in writing via an ABN if the supplier wants to collect money f rom a beneficiary if an item is denied.   When a supplier furnishes an upgraded item of DMEPOS and the supplier expects Medicare to reduce the level of payment based on a medical necessity partial denial of coverage for additional expenses attributable to the upgrade, the supplier must give an ABN to the beneficiary for signature for holding the beneficiary liable for the additional expense.  Optional ABN forms are available at:  http://www.cms.gov/Medicare/Medicare -General -Information/BNI/ABN.html .   A. General Instructions for the Use of ABNs for Upgrading DMEPOS Items   Instruction  Description  1. An upgrade may be from one item to another within a single Heath Insurance Common Procedure Coding System (HCPCS) code, or may be from one HCPCS code to another.  When an upgrade is within a single code the upgraded item must include features that exceed t he official code descriptor for that item.  2. The upgrade must be within the range of items or services that are medically appropriate for the beneficiarys medical condition and the purpose of the physicians order.  ABNs may not be used to substitute a different item or service that is not medically  appropriate for the beneficiarys medical condition for the original item or service.  The upgraded item must still meet the intended medical purpose of the item the physician ordered.  3. Use of an ABN to furnish an upgraded item or service, with the beneficiary being personally responsible for the difference between the costs of the standard and upgraded item or service, does not change coverage or payment rules, statutory provisions, or m anual instructions for the particular benefit involved.   4. In cases where the DME MACs would make payment for the item the physician ordered on a rental basis, the supplier must furnish the upgrade on a rental basis.   5. A supplier furnishing an upgrade and using an ABN must submit a claim and include information on the claim that identifies the upgrade features.  Suppliers must submit a claim for upgraded items and services using the GA modifier on the upgraded line item to indicate that the beneficiary signed an ABN.  Suppliers must list upgrade features using the ASC X12 837 professional claim format or on the paper Form CMS -1500 in Item 19 or as an attachment to the claim for paper claims.  6. Denials should be based on medical necessity.   B. Billing Instructions:   Suppliers must bill 2 line items for upgraded DMEPOS items where the beneficiary requests an upgrade.  Suppliers must bill both lines on the same claim in the following order:   Line Instruction  Line 1:  Bill the appropriate HCPCS code for the upgraded item the supplier actually provided to the beneficiary with the dollar amount of the upgraded item.  If the supplier has a properly obtained ABN on file signed by the beneficiary, use the GA modifier.  If the supplier did not properly obtain an ABN signed by th e beneficiary, use the GZ modifier.  Line 2:  Bill the appropriate HCPCS code for the reasonable and necessary item with the actual charge for the item.  Use the GK modifier.   Suppliers should bill their full submitted charge on the claim line for the upgraded item (Line 1) and the full amount for the reasonable and necessary item (Line 2).  If the upgrade is within a code, suppliers still bill 2 line items, using the same code on both lines, but Line 1 would have the higher dollar amount.  Suppliers must bill both lines on the same claim in sequential order.  Line 1 and the associated Line 2 should follow each other.   DME MACs must return/reject applicable assigned claims that have invalid ABN upgrade information using appropriate messages.  If the claim is unassigned, DME MACs must issue a denial.   C. Definitions of Modifiers that May be Associated with ABNs   Modifier  Description  GA -  Waiver of Liability (expected to be denied as not reasonable and necessary, ABN on file)  GZ -  Item or Service not Reasonable and Necessary (expected to be denied as not reasonable and necessary, no ABN on file)  GK -  Reasonable and necessary item/service associated with GA or GZ modifier   D. Medicare Summary Notice (MSN) and Remittance Advice (RA)   MSN  Detailed text  36.01:  Our records show that you were informed in writing, before receiving the service that Medicare would not pay.  You are liable for this charge.  If you do not agree with this statement, you may ask for a review.  ASC X12 835, remittance advice remark code M 38 36.02:  It appears that you did not know that we would not pay for this service  so you are not liable.  Do not pay your provider for this service.  If you have paid your provider for this service, you should submit to this office three things 1) A copy of this notice, 2) Your providers bill, and 3) A receipt or proof that you have paid the bill.  You must file your written request for payment within 6 months of the date of this notice.  Future services of this type provided to you will be your responsibility. ASC X12 835 remittance advice remark code M25)  8.51:  You signed an Advanced Beneficiary Notice (ABN).  You are responsible for the difference between the upgrade amount and the Medicare payment.   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