🪑 Medicare Cheat Sheet — Free Upgrade Cushions
Use this when a free upgrade cushion is provided to a Medicare beneficiary (no patient charge).
⚡ QUICK STEPS
| Step | Task | What to Do | Where |
|---|---|---|---|
| 1 | Add Free Upgrade Item | Enter the upgrade cushion (E2607, etc.) so it prints on the POD. Include make/model and note what it’s a free upgrade from. | Items Tab |
| 2 | Add Note | Note example: “Free upgrade from E2601” | Item Note |
| 3 | Remove insurance | Remove insurance from free item and zero out the charge and allowable. | Item |
| 4 | Add Medically Necessary Cushion | Bill the covered cushion (E2601) as normal. | Items Tab |
| 5 | Apply Modifiers | Add required modifiers (see list below). | Claim Line |
| 6 | Add Claim Narrative | Enter “Free upgrade to E2607” to explain higher-level item. | Claim Line |
| 7 | Review POD | POD must show both cushions (upgrade + medically necessary). | POD Tab |
💡 CLAIM SUBMISSION SUMMARY
- Only the medically necessary cushion (E2601) is submitted for payment.
- The GL modifier is required to show a free upgrade was provided.
- Include the claim narrative:
FREE UPGRADE TO E2607 - Do not bill the upgrade cushion line to Medicare (it’s informational only).
- Ensure POD lists both items for audit support.
🧩 MODIFIER QUICK REFERENCE
| Modifier | Meaning | When to Use |
|---|---|---|
| GL | Free upgrade provided, no charge to patient | Always used for free upgrades |
| KU | For CRT MWC or Group 3 PWC bases | Only if applicable |
| KX | Coverage criteria met | Standard coverage modifier |
| NU | New equipment | Required for new cushion |
| GA / GK / GZ | Not used for free upgrades | Only for chargeable upgrades |
🧾 DOCUMENTATION REQUIREMENTS
- Item note must clearly state “Free upgrade from [HCPCS code]”
- Make & model # included for PDAC verification
- Claim narrative states “Free upgrade to [HCPCS code]”
- GL modifier on the medically necessary cushion line
- POD must list both items with correct description and $0.00 charge for upgrade
✅ FINAL CHECKLIST
- Free upgrade item listed in Sales Order
- “Free upgrade from [HCPCS code]” in item note
- Free item has insurance removed and Charge/Allowable “zero’d out”
- GL modifier added to medically necessary cushion line
- Claim narrative entered
- KU used only if base is CRT MWC or Group 3 PWC
- POD shows both cushions
- Make/model verified for PDAC compliance
Tip
GL = Given at no charge. Always double-check it’s added — missing this is the #1 cause of free-upgrade denials.
Info
Reference: Noridian Upgrades Policy (Jurisdiction C)
STEPS
