Upgrading to a Custom Brace

Chapter 20, Transmittal 120 of the Medicare Claims Processing Manual lays out the appropriate way to deliver an upgraded device to a beneficiary in conjunction with an Advance Beneficiary Notice. If you follow these guidelines closely, Medicare will pay for the cost of the basic product and you can limit the patient's financial responsibility to the difference between that and the upgraded device you deliver.

There are 3 steps you must follow:

1. Explain to the patient that you can provide  an upgraded item, but there will be financial responsibility for the difference between the custom brace and the base item that Medicare will pay for.
2. Have the patient sign an ABN confirming that explanation.
3. When submitting the claim, put the code for the actual item provided (i.e., the upgraded item) on the first line of the claim using the "GA" modifier. List the code for the covered item on the second line using the "GK" modifier." 

Example: Your patient needs an OA Unloader Brace (L1843). The physician has documented medical necessity, including intability of the knee. The patient wants a custom-fit brace and needs it to fit inside ski boots.

You explain  that you can bill for a custom brace, but Medicare will not pay for the customization. Medicare will pay for the cost of the basic brace that's medically necessary and the patient is responsible for the difference in cost between that and the upgraded version. You then have the patient execute an ABN consistent with that discussion. Finally, you bill Medicare as follows:

• L1844 – GA Custom Unloader Brace
• L1843 – GK OTS Unloader Brace

Medicare will deny the first line as "not medically necessary with patient responsibility." It will then pay the second line according to its normal procedures so long as you adequately document medical necessity). This applies to private payer claims, as well.

Both the patient and you will receive a statement showing patient's financial liability as the difference between the submitted charge for the provided item and the submitted charge for the covered item, taking deductible and coinsurance into consideration.