Home Health & Hospice Week

Know your modifiers.

Knowing is half the battle, and that's especially true for Medicare reimbursement rules.

To make sure you receive your rightful payment for upgraded items of durable medical equipment you furnish, follow these five steps the Centers for Medicare & Medicaid Services outlines in a new transmittal:

1. Obtain an ABN signed by the beneficiary. The advance beneficiary notice must outline the upgraded features and note that CMS won't pay for them.

2. Obtain a physician's order and a certificate of medical necessity (CMN) for the originally ordered item.

3. List on the claim a line item for the upgraded piece of DME that you are furnishing. The line should include the HCPCS code for the upgraded piece of equipment; a modifier showing that an ABN was properly obtained (GA) or not properly obtained (GZ); and the full charge for the item.

4. List an accompanying, second line item for the originally ordered piece of equipment that you are not furnishing. The line should include the HCPCS code for the originally ordered piece of equipment; a modifier (GK) showing that the physician ordered it, but you aren't furnishing it due to the upgrade; and the full charge for the item.

In cases where the items are within the same HCPCS code, you would use the same code for each line, but would have different charge amounts for them.

5. Include a description of the upgraded piece of DME using Item 19 or an attachment to a paper claim, or using the HA0 record for an electronic claim. After HIPAA electronic standards take effect in October, you must use the NTE segment/line note on the 837 electronic claim, CMS notes.