Medicare_Claims_Processing_Manual / 100-04 Change Request 5367

Why This Topic Matters

The article clarifies how Medicare wants upgraded DMEPOS items reported and processed, which affects claim submission, beneficiary liability, and denial handling. It also helps providers align documentation and claim formatting with CMS instructions that became effective in 2007.

Article Sections

1. DMERCs - Billing Procedures Related to Advanced Beneficiary Notice (ABN) Upgrades

   Overview of the manual instructions for upgraded DMEPOS items, including the role of ABNs, claims handling, and related billing documentation. The section also discusses the general framework for beneficiary liability and claim processing.

2. General Instructions for the Use of ABNs for Upgrading DMEPOS Items

   General policy considerations for upgrades within the DMEPOS billing context, including claim reporting and documentation requirements. This section addresses the broader administrative setup for upgraded items.

3. Billing Instructions

   Claim-line billing structure and sequencing guidance for upgraded DMEPOS items, including how the claim should reflect the upgraded and non-upgraded items. This section also covers claim handling when ABN information is present or absent.

4. Definitions of Modifiers that May be Associated with ABNs

   A summary of the modifiers referenced in connection with ABN-related upgrade claims. The section is limited to the billing context and Medicare processing notes.

5. Medicare Summary Notice (MSN) and Remittance Advice (RA)

   Medicare notice and remittance messaging associated with upgrade-related claims and denials. This section identifies the types of beneficiary-facing messages tied to the claim-processing scenarios described in the article.

6. Providing Upgrades of DMEPOS Without Any Extra Charge

   Policy and billing guidance for situations where an upgraded DMEPOS item is furnished without charging extra beyond the non-upgraded item. The section explains the general administrative treatment of these claims and the related claim notation requirements.

7. Policy

   The policy framework for furnishing upgraded DMEPOS items without additional charge to the beneficiary or Medicare. This section describes the circumstances under which the billing approach is permitted.

8. Billing Instructions

   Billing and documentation instructions for the no-extra-charge upgrade scenario, including the claim presentation and related modifier usage. It also addresses how supporting information should be recorded.

9. MSN Message

   The beneficiary notice message associated with claims processed under the no-extra-charge upgrade scenario. This section provides the notice category used in Medicare communications.