Home Health & Hospice Week

If you're passing up the opportunity to use newly sanctioned durable medical equipment upgrades, you could be letting profitable business slip through your fingers. Medicare now gives beneficiaries the option of paying for the difference between a Medicare-covered piece of DME and one with extra features. But suppliers and beneficiaries alike often are fuzzy on the fairly new concept. "It's very confusing," says Sarah Lott with Texas Star Medical Billing in Vidor, TX. And the Centers for Medicare & Medicaid Services hasn't been very forthcoming with clear directions, adds Nicole Thiroux with DMExpress Billing Service in Northridge, CA. Even when suppliers understand the procedures, they often don't want the paperwork hassle that accompanies an upgrade, Thiroux says. "They are set in their ways." Many suppliers simply don't think of offering a patient an upgrade, observes Roberta Domos with Domos HME Consulting in Redmond, CA. "They aren't in the habit of trying to up-sell the patient, particularly when there isn't an obvious need," Domos believes. But suppliers may change their tune now that CMS has issued detailed new instructions that clarify how DME upgrades work. Every upgrade should include the following elements, CMS says in July 18 Transmittal No. 1809, an addition to the Medicare Carriers Manual: ABNs. To ensure the beneficiary must pay for the difference between a Medicare-covered item and an upgraded one, a supplier must obtain a signed advance beneficiary notice from the customer. "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," CMS says in the transmittal. Without an ABN signed in advance, the supplier can't hold a beneficiary liable for the upgrade's cost, CMS stresses. Suppliers should write on the ABN the additional features of the upgraded item, a CMS official said in a June 25 special Open Door Forum for DME. "Don't write in all the equipment," the CMS staffer said. "Just write in whatever it is that's additional, the reason for which the ABN is being given." The ABN is the most important part of billing for upgrades, Thiroux emphasizes. "Patients have to sign ahead of time." Physician orders. The upgrade provision doesn't allow beneficiaries and suppliers to get around normal Medicare coverage or payment rules, CMS stressed in the forum. Suppliers must have physician orders for the original, non-upgraded DME item. "ABNs may not be used to substitute a different item or service that is not medically appropriate for the beneficiary's medical condition for the original item or service that the physician originally ordered," CMS explains in the transmittal. "The upgraded item must still meet the intended medical purpose [...]