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Home Health & Hospice Week

Reimbursement:

Market DME Upgrades to Maximize Income

Published on Thu Feb 24, 2005

Medicare gives patients what they need, but you can give them what they want.

Attention, durable medical equipment suppliers: If your business isn't doing all it can to promote equipment upgrades to customers, you're missing out on easy money.

That was the message reimbursement specialist Andrea Stark of Greenville, SC-based MiraVista delivered recently to a meeting of the North Carolina Association of Medical Equipment Suppliers. In a presentation on the effective use of advanced beneficiary notices, Stark observed that too many suppliers fail to take full advantage of all the tools at their disposal for making money - and that includes using ABNs for equipment upgrades.

"You need to get your wheels spinning," Stark said. "How are you going to market to your customer that they need to upgrade?"

An upgrade is defined as something that is not only more expensive than a standard item but is also distinguishably different from that standard item. An upgrade may offer more features or components, for example, or it may be greater in quantity than what the physician ordered.

Key idea: To qualify as an upgrade, however, an item must be within the range of services appropriate for the beneficiary's condition, Stark noted. In other words, someone who needs a walker can't get a wheelchair and call it an upgrade. The upgraded items must also be in the same fee schedule category as the standard item.

Take action: Go through your DME showroom and pick out one or two items to showcase as standard Medicare items. Then set up another display of similar but upgraded items.

"It's a great marketing tool, because they'll want the fancier one," Stark observed.

Learn the ABCs of ABNs

If your customer has a prescription for a standard item but prefers an upgraded item, have him sign an ABN agreeing to shoulder responsibility for the difference between the charges. This allows you to collect the difference between your retail charges for the standard and upgraded items.

Say, for example, a customer has a prescription for a standard semi-electric hospital bed (HCPCS codeE0260). Show her that bed - but also show her a total electric bed (E0265), perhaps pointing out how the upgraded item would make life easier for her caregiver. Should the customer choose the more expensive item, have her sign an ABN pledging to accept responsibility for the difference in the price of the two items.

According to Stark, other common situations where an upgrade is possible include:
 

  • standard wheelchair to light wheelchair (K0001 to K0004);
     
  • standard walker to multiple braking system walker (E0141 to E0147);
     
  • standard nebulizer to portable nebulizer (E0570 to E0571);
     
  • standard commode to seat lift commode (E0165 to E0169);
     
  • standard glucometer to specialty monitor (E0607 to E2100);
     
  • standard silicone breast prosthesis to custom prosthesis (L8030 to L8035); and
     
  • non-segmented lymphedema pump to segmented pump (E0650 to E0652).

    Use Modifiers to Cover Your Bases

    When billing for an upgrade, use the "GA" modifier to identify the upgraded item, Stark counseled. That indicates you have a valid, signed ABN on file and you advised the customer of his financial responsibility. Then use the "GK" modifier to identify the standard item that the customer chose not to receive.

    But keep in mind that you can't use an upgrade ABN to collect on items specifically ordered by a physician, Stark warned. In other words, if on his prescription the doctor writes, "total electric hospital bed," he leaves you no room to upgrade the item.

    Hint: Educate the physicians you work with on the importance of writing generic prescriptions.

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