Use of Upgrade Modifiers
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Use of Upgrade Modifiers
 
An upgrade is defined as an item that goes beyond what is medically necessary under Medicare's coverage requirements.  An item can be considered an upgrade even if the physician has signed an order for it.  When suppliers know that an item will not be paid in full because it does not meet the coverage criteria stated in the LCD, the supplier can still obtain partial payment at the time of initial determination if the claim is billed using one of the upgrade modifiers, GK or GL.  The descriptions of the modifiers are:
  • GK - Reasonable and necessary item/service associated with a GA or GZ modifier
  • GL - Medically unnecessary upgrade provided instead of non-upgraded item, no charge, no ABN
If a supplier wants to collect from the beneficiary for the upgraded item provided, a properly completed ABN must be obtained.  If an ABN is obtained, on one claim line the supplier bills with a GA modifier the HCPCS code that describes the item that was provided.  On the next claim line, the supplier bills with a GK modifier the HCPCS code that describes the item that is covered based on the LCD.  (Note: The codes must be billed in this specific order on the claim.)  In this situation, the claim line with the GA modifier will be denied as not medically necessary with a "patient responsibility" (PR) message and the claim line with the GK modifier will continue through the usual claims processing.  The beneficiary liability will be the sum of (a) the difference between the submitted charge for the GA claim line and the submitted charge for the GK claim line and (b) the deductible and co-insurance that relate to the allowed charge for the GK claim line.  The supplier's charge for the upgraded item that is provided may not exceed the applicable fee schedule amount (if any) for that item.
 
If a supplier wants to provide the upgraded item without any additional charge to the beneficiary, then no ABN is obtained. If it is the supplier's decision to provide the upgraded item at no additional charge to the beneficiary or if physician ordered the upgraded item and the supplier decides to provide it at no additional charge to the beneficiary, the supplier bills with a GL modifier the HCPCS code that describes the item that is covered based on the LCD.  In this situation, the supplier does not bill the HCPCS code that describes the item that was provided.
If the request for the upgraded item is from the beneficiary and the supplier decides to provide it at no additional charge, no ABN is obtained.  On one claim line the supplier bills with a GZ modifier the HCPCS code that describes the item that was provided.  On the next claim line, the supplier bills with a GK modifier the HCPCS code that describes the item that is covered based on the LCD.  (Note: The codes must be billed in this specific order on the claim.)
 
 
Suppliers are reminded that if there is a requirement in a specific policy to use a KX modifier to indicate that an item meets coverage criteria, then it is used in addition to the GK or GL modifier.  Codes with a GK or GL modifier will continue through the usual claims processing.  Other edits may cause the GK/GL claim line to be denied. However, if no other edits are involved, payment will be made based on the fee schedule for the code with the GK or GL modifier.
 
Further instructions will be forthcoming concerning the options that a supplier has if a claim is submitted without upgrade modifiers and is denied as not medically necessary and the supplier subsequently decides that it would like to utilize the upgrade modifiers.
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