Upgrade modifiers and resubmit the claim

Resubmitting Claims with Upgrade Modifiers - Effective 02/04/2011

Recently the Durable Medical Equipment Medicare Administrative Contractors (DME MAC) issued bulletin articles regarding the use of upgrade modifiers in conjunction with HCPCS codes subject to the elimination of least costly alternative (LCA). For certain items that were previously subject to LCA, suppliers will now receive a not reasonable and necessary denial. The article indicated that further instructions would be forthcoming concerning the options that a supplier has if a claim for an item previously subject to LCA is submitted without upgrade modifiers, is subsequently denied as not reasonable and necessary and the supplier decides that it would like to utilize the upgrade modifiers.

For items that were previously subject to LCA, suppliers have the option of resubmitting the claim using the upgrade modifiers and the code for the covered medically necessary item rather than exercising the option of Appeals. For example, a supplier submits a claim after February 04, 2011 for code E0265 (fully electric hospital bed) and the claim is denied as not reasonable and necessary. That claim may be resubmitted with code E0265 and the appropriate modifiers on Line 1 and code E0260 and the appropriate modifiers on Line 2. Resubmitting the claim in this fashion will not result in a conflict with the original code E0265 claim and subsequent duplicate claim denial.

These resubmission instructions apply only to items previously subject to LCA payment policy that now receive not reasonable and necessary denials. Other items receiving reasonable and necessary denials must follow the usual redeterminations process.