Since becoming fully effective on Jan. 1, 2002, Medicare's new equipment upgrade provision makes it easier for customers to get equipment that meets their needs and desires beyond the strict definition of medical necessity. Happier customers confident of Medicare's basic reimbursement and willing to pay their share for additional features create more sales for you.

The upgrade mechanism is a simple, one-page form: Advance Beneficiary Notice (ABN), Form No.

CMS-R-131-G. It tells customers, before they buy upgraded equipment, that ''Medicare probably will not pay for'' it on that particular occasion.

As of April 1, 2002, there are new instructions for billing upgraded items.

Only Three Boxes
As the provider, you need to fill in just three blanks. Your customer then elects to receive or not to receive the items or services, and signs the form. Two boxes appear under the statement ''Medicare probably will not pay for.

Box 1- Items or Services. This is not the entire piece of equipment just the upgrade feature, which will probably be denied because it is an ''excess component ... in addition to, or is more extensive and/or more expensive than, the item or service ordered by the physician, and which is reasonable and necessary under Medicare's coverage requirements.'' If, for example, the physician ordered a manual wheelchair but the patient wants a power wheelchair, the ''Items or Services'' box would specify the motorized feature (not the entire motorized wheelchair).

An ABN may not charge more for ''higher quality'' equipment without indicating an 11 excess component.'' Simply charging more for premium quality violates Medicare payment limits and applicable charge limits.

Box 2- Because. it asks why Medicare is expected to deny coverage. The answer is commonly because the item or service is not ''reasonable and necessary,'' or your customer's condition ''does not support the need for (the upgrade).''

Box 3- Estimated Cost. This is the cost of the upgrade that the customer will pay out of pocket, not the total equipment cost.

Upgrade Limitations
An ''upgrade'' is defined as ''an item with features that go beyond what the physician ordered.'' The upgrade may be made from one item to another within the same HCFA Common Procedure Coding System (HCPCS) code, or may be made from one code to another.

But ''The upgraded item must still meet the intended and medical necessity purpose of the physician-ordered item.'' It cannot be inconsistent with the physician's order and inappropriate for the customer's medical condition. A Medicare Learning Network FAQ gives the example that ''ABNs may not be used for substitution of a wheelchair when a cane was prescribed.''

New Billing Instructions
As of April 1, suppliers are required to bill two line items on the same claim when the beneficiary requests an upgraded item.

On line 1, the item provided to the beneficiary is billed with its appropriate HCPCS code. The dollar amount is the cost of the upgraded item. Use a modifier after the HCPCS: GA if an ABN is on file, GZ if no ABN is on file.

On line 2, the item ordered by the physician is charged, with the cost of the actual charge or fee-schedule amount. ''GK'' is used after the HCPCS, indicating that it is the actual item ordered by the physician and is associated with the GA or GZ item.

The two lines must be consecutive, not separated by other line items on the form (HCFA-1 500).

Put the Customer First
The upgrade provision increases retail opportunities, but focus on your customers' needs rather than just ''upselling" at every opportunity. After all, the physician prescribed specific equipment, and upgrades may be unsafe or inappropriate. Medicare has indicated that it may review upgrade claims and deny those that are not what the physician wanted.

Resources
DMERCs-Advance Beneficiary Notices for Upgrades.
www.hcfa.gov/pubforms/transmit/bOl 64.pdf

ABN Form No. CMS-R-131-G
www.hcfa.gov/medlearn/cmsrl3lg.pdf

Medicare Learning Network
www.hcfa.gov/medlearn/faqdmepo.htm

 
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