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Miscellaneous HCPCS (A9999 and E1399)

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You can use the following codes to request miscellaneous CPAP-related supplies:

  • A9999 for accessories
  • E1399 for device-related supplies

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Client services representatives and Faith (the interactive voice response system) don't typically ask patients if they require miscellaneous supplies during outreach. However, these codes allow you to offer other supplies to the patient to maximize the supply request and maintain all details within ResMed ReSupply for better reporting.

Examples of miscellaneous items include:

If you're unsure which HCPCS code applies to the miscellaneous supply item, begin to type the description in the Description field. The appropriate code displays and then you can select it.

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Sleep Medicine Codes

International classification of disease (icd-10 – clinical modification ( cm)) diagnostic coding system.

The 10th revision of the International Classification of Diseases and related health problems (ICD-10-CM) is a uniform diagnostic coding system.  Maintenance of ICD-10-CM is the responsibility of the CDC’s National Center for Health Statistics (NCHS) under authorization by the World Health Organization (WHO). In practice, ICD-10-CM has become the international standard diagnostic classification for all general epidemiological and many health-management purposes that translates diagnoses into a seven-character, alphanumeric code, which permits easy storage, retrieval, and analysis of the data. ICD-10-CM classifies diagnoses and reasons for visits in all health care settings, and is primarily used to categorize, and describe general types of injuries and diseases, and identify medical diagnoses furnished by physicians and other health care professionals. Visit the AASM Store to access the most current version of the authoritative clinical text for the diagnosis and treatment of sleep disorders, the International Classification of Sleep Disorders.

Current Procedural Terminology (CPT®) Codes

The CPT code set is a uniform coding system consisting of descriptive terms and identifying codes (5 numeric digits) that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals. The CPT code set is maintained by the American Medical Association (AMA) and decisions regarding addition, deletion or revision of CPT codes are made by the CPT Editorial Panel. Although not all-inclusive, the below tables list some of the more frequently used codes in sleep medicine.

Sleep Services Codes

Note: Use the Technical Component (TC) modifier when only the technical component is billed and the 26 (professional component) modifier when only the professional component is billed.

Evaluation and Management (E/M Codes)

Sleep physicians also use Evaluation and Management codes to bill for office visits. Assigning codes for office visits can be complex, however, Medicare has an Evaluation and Management Services guide you can refer to for more information.

Evaluation and management codes are restricted to physicians and other qualified advanced nurse practitioners (NPs, PAs, etc.). Technologists cannot bill independently but they can bill incident to the physician (if certain guidelines are followed).

Find more information about the E/M Code Changes, here .

E/M Add-on Code

Healthcare common procedural coding system (hcpcs).

HCPCS is divided into two subsystems: Level I (comprised of the CPT code set) and Level II. Level II of the HCPCS is a standardized coding system (a single alphabetical letter followed by 4 numeric digits) that is primarily used to identify products, supplies and services not included in the CPT code set. HCPCS Level II codes include ambulance services and durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) when used outside a physician’s office.

G Codes (home sleep apnea testing)

The G codes (G0398, G0399 and G0400), which describe home sleep apnea testing (HSAT) services, were added to the Healthcare Common Procedure Coding System (HCPCS) Level II in 2008. Some insurers accept the G codes while others accept the CPT® codes for HSATs (95800, 95801 and 95806). An HSAT provider will need to contact each insurer they work with to identify which codes can be reported.

Durable Medical Equipment (DME) Sleep Medicine Codes

All E codes fall under the jurisdiction of the DME MAC unless otherwise noted.

Psychology/Psychiatry Codes

Note: CPT Copyright 2021 American Medical Association.  All rights reserved. CPT® is a registered trademark of the American Medical Association.

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Common hcpcs codes for sleep therapy and oxygen equipment & supplies

Although Sleep Restfully, Inc does not file claims with your insurance company for reimbursement many insurance companies will consider claims filed directly by the insured party.  These claims must contain the appropriate HCPCS code in order to be considered.  In an effort to assist out customers in filing a claim we are providing a list of the most common HCPCS codes used for sleep therapy and oxygen therapy equipment and supplies.

CPAP/BiLevel Michine HCPCS Codes:

E0601 Continuous airway pressure device (CPAP/APAP)

E0470 Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

E0471 Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

E0472 Respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure device)

E0571 Humidifier, non-heated, used with positive airway pressure device

E0562 Humidifier, heated, used with positive airway pressure device

CPAP/Bi-Level Mask HCPCS Codes

A7030 Full face mask used with positive airway pressure device, each

A7034 Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap

A7044 Oral interface used with positive airway pressure device

A7027 Combination oral/nasal mask, used with continuous positive airway pressure device, each

CPAP & Bi-Level Parts and Accessories

A4604 Heated Tube used with Positive airway pressure device

A7028 Oral cushion for combination oral/nasal mask, replacement only, each

A7029 Nasal pillows for combination oral/nasal mask, replacement only, pair

A7031 Face mask interface, replacement for full face mask, each

A7032 Cushion for use on nasal mask interface, replacement only, each

A7033 Pillow for use on nasal cannula type interface, replacement only, pair

A7035 Headgear used with positive airway pressure device

A7036 Chinstrap used with positive airway pressure device

A7037 Tubing used with positive airway pressure device

A7038 Filter, disposable, used with positive airway pressure device

A7039 Filter, non disposable, used with positive airway pressure device

A7045 Exhalation port with or without swivel used with accessories for positive airway devices, replacement only

A7046 Water chamber for humidifier, used with positive airway pressure device, replacement, each

Oxygen Concentrators & Supplies

A4615 Oxygen Nasal Cannula

A4616 Oxygen Supply Tubing

E0445 Oximeter device for measuring blood oxygen levels non-invasively

E1356 Oxygen accessory, battery pack/cartridge for portable concentrator, any type, replacement only, each

E1357 Oxygen accessory, battery charger for portable concentrator, any type, replacement only, each

E1358 Oxygen accessory, dc power adapter for portable concentrator, any type, replacement only, each

E1390 Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate

E1392 Portable oxygen concentrator

Miscellaneous Medical Equipment

E1399 Durable medical equipment, miscellaneous

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Insurance Codes

CPAP Network  does not bill any insurance, Medicare or Medicaid. We are a free-market provider which allows us to offer the most cost-effective options to people with high deductibles. If you have a high deductible health plan, you are basically self-insured until your deductible is met. This is where smart out-of-pocket purchasing can be the most economical and hassle-free.  

If you choose to submit an insurance claim form for reimbursement, CPAP Network will assist by providing a detailed purchase order with all the required data. Below are the HCPCS codes you may need for the claim form:

HCPCS CODES

CPAP/BiPAP MACHINE 

E0601  - Continuous airway pressure (CPAP/APAP) device

E0470  - Respiratory assist device, bi-level pressure (BiPAP) capability, WITHOUT backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

E0471  - Respiratory assist device, bi-level pressure (BiPAP) capability, WITH backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

E0472  - Respiratory assist device, bi-level pressure (BiPAP) capability, WITH backup rate feature, used with invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure device)

E0561  - Humidifier, non-heated, used with positive airway pressure (CPAP/BiPAP/APAP) device

E0562  - Humidifier, heated, used with positive airway pressure (CPAP/BiPAP/APAP) device

CPAP/BiPAP MASK

A7030  - Full Face Mask used with Positive Airway Pressure (CPAP/BiPAP/APAP) Device

A7034  - Nasal interface (mask or cannula type) used with positive airway pressure (CPAP/BiPAP/APAP) device , with or without headstrap

A7044  - Oral interface used with positive airway pressure (CPAP/BiPAP/APAP) device

A7027  - Combination oral/nasal mask, used with continuous positive airway pressure device

CPAP/BiPAP PARTS & ACCESSORIES

A7028  - Oral cushion for combination oral/nasal mask

A7029  - Nasal pillows for combination oral/nasal mask

A7031  - Replacement Cushion for Full Face Mask

A7032  - Replacement Cushion for Nasal Mask

A7033  - Replacement Pillows for Nasal Mask

A7035  - Headgear used with positive airway pressure device

A7036  - Chinstrap used with positive airway pressure device

A7037  - Tubing used with positive airway pressure device

A4604  - Heated Tubing used with positive airway pressure device

A7038  - Filter, disposable, used with positive airway pressure device

A7039  - Filter, non-disposable (reusable), used with positive airway presssure device

A7045  - Exhalation port with or without swivel used with accessories for positive airway pressure devices

A7046  - Water chamber for humidifier, used with positive airway pressure device

E1399  - Miscellaneous Durable Medical Equipment Items, Components and Accessories

( CPT  is a code set to describe medical, surgical ,and diagnostic services;  HCPCS  are codes based on the CPT to provide standardized coding when healthcare is delivered) 

OTHER INFO: 

Provider Diagnosis Code

Diagnosis code for Obstructive Sleep Apnea is G47.33 (contact your provider for your specific diagnosis code) Our Company Information Most frequently requested information: CPAP Network LLC 1437 Egg Harbor Road Sturgeon Bay, WI  54235 Phone: 888.293.4811 Fax: 920.367.0533 Tax ID Number: 82-5030164

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Tracking Sheet

Positive airway pressure (pap) devices for the treatment of obstructive sleep apnea, document note, note history, contractor information, lcd information, document information.

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023 , the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

The LCD is revised to align refill requirements with CMS Final Rule CMS-1780-F. This revision allows contact with the beneficiary regarding refills to take place no sooner than 30 calendar days prior to the end of the current supply and to document an affirmative response.

No proposed LCD issued.

CMS National Coverage Policy

CMS Pub. 100.03 (Medicare National Coverage Determination Manual), Chapter 1, Section 240.4

Coverage Guidance

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. The purpose of a Local Coverage Determination (LCD) is to provide information regarding “reasonable and necessary” criteria based on Social Security Act § 1862(a)(1)(A) provisions. In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement:

The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.

The LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.

Refer to the Supplier Manual for additional information on documentation requirements.

Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD.

For the items addressed in this LCD, the “reasonable and necessary” criteria, based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity. DEFINITIONS: Apnea is defined as the cessation of airflow for at least 10 seconds. Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds associated with at least a 30% reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a 4% decrease in oxygen saturation. The apnea-hypopnea index (AHI) is defined as the average number of episodes of apnea and hypopnea per hour of sleep without the use of a positive airway pressure device. For purposes of this policy, respiratory effort related arousals (RERAs) are not included in the calculation of the AHI. Sleep time can only be measured in a Type I (facility based polysomnogram) or Type II sleep study (see descriptions below). The respiratory disturbance index (RDI) is defined as the average number of apneas plus hypopneas per hour of recording without the use of a positive airway pressure device. For purposes of this policy, respiratory effort related arousals (RERAs) are not included in the calculation of the RDI. The RDI is reported in Type III, Type IV, and other home sleep studies. If the AHI or RDI is calculated based on less than 2 hours of sleep or recording time, the total number of recorded events used to calculate the AHI or RDI (respectively) must be at least the number of events that would have been required in a 2 hour period (i.e., must reach ≥30 events without symptoms or ≥10 events with symptoms). INITIAL COVERAGE:

In this policy, the term PAP (positive airway pressure) device will refer to both a single-level continuous positive airway pressure device (E0601) and a bi-level respiratory assist device without back-up rate (E0470) when it is used in the treatment of obstructive sleep apnea.

  • An E0601 device is covered for the treatment of obstructive sleep apnea (OSA) if criteria A – C are met:
  • The beneficiary has an in-person clinical evaluation by the treating practitioner prior to the sleep test to assess the beneficiary for obstructive sleep apnea.
  • The beneficiary has a sleep test (as defined below) that meets either of the following criteria (1 or 2):
  • The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events; or,
  • The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of:
  • Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or,
  • Hypertension, ischemic heart disease, or history of stroke.
  • The beneficiary and/or their caregiver has received instruction from the supplier of the device in the proper use and care of the equipment.

If a claim for an E0601 is submitted and all of the criteria above have not been met, it will be denied as not reasonable and necessary.

  • An E0470 device is covered for those beneficiaries with OSA who meet criteria A-C above, in addition to criterion D:
  • An E0601 has been tried and proven ineffective based on a therapeutic trial conducted in either a facility or in a home setting.

Ineffective is defined as documented failure to meet therapeutic goals using an E0601 during the titration portion of a facility-based study or during home use despite optimal therapy (i.e., proper mask selection and fitting and appropriate pressure settings). If E0470 is billed for a beneficiary with OSA and criteria A-D are not met, it will be denied as not reasonable and necessary. A bi-level positive airway pressure device with back-up rate (E0471) is not reasonable and necessary if the primary diagnosis is OSA. If an E0471 is billed with a diagnosis of OSA, it will be denied as not reasonable and necessary. If an E0601 device is tried and found ineffective during the initial facility-based titration or home trial, substitution of an E0470 does not require a new initial in-person clinical evaluation or a new sleep test. If an E0601 device has been used for more than 3 months and the beneficiary is switched to an E0470, a new initial in-person clinical evaluation is required, but a new sleep test is not required. A new 3 month trial would begin for use of the E0470. Coverage, coding and documentation requirements for the use of E0470 and E0471 for diagnoses other than OSA are addressed in the Respiratory Assist Devices (RAD) Local Coverage Determination (LCD) and related Policy Article (PA). Sleep Tests

Coverage and Payment rules for diagnostic sleep tests may be found in the CMS National Coverage Determination (NCD) 240.4.1 (CMS Pub.100-03, Chapter 1, Part 4), the applicable A/B MAC LCDs and Billing and Coding articles. The sleep test must be either a polysomnogram performed in a facility-based laboratory (Type I study) or an inpatient hospital-based or home-based sleep test (HST) (Types II, III, IV, Other).

Coverage of a PAP device for the treatment of OSA is limited to claims where the diagnosis of OSA is based upon all of the following:

A sleep test (Type I, II, III, IV, Other) that meets the Medicare requirements for a valid sleep test as outlined in NCD 240.4.1 and the applicable A/B MAC LCD and Billing and Coding article; and,

A sleep test that is approved by the Food and Drug Administration (FDA) as a diagnostic device; and,

The sleep test results meet the coverage criteria in effect for the date of service of the claim for the PAP device; and,

The sleep test is ordered by the beneficiary’s treating practitioner; and,

  • The sleep test is conducted by an entity that qualifies as a Medicare provider of sleep tests and is in compliance with all applicable state regulatory requirements. 

CONTINUED COVERAGE BEYOND THE FIRST THREE MONTHS OF THERAPY:

Continued coverage of a PAP device (E0470 or E0601) beyond the first three months of therapy requires that, no sooner than the 31st day but no later than the 91st day after initiating therapy, the treating practitioner must conduct a clinical re-evaluation and document that the beneficiary is benefiting from PAP therapy.

For PAP devices with initial dates of service on or after November 1, 2008, documentation of clinical benefit is demonstrated by:

1. In-person clinical re-evaluation by the treating practitioner with documentation that symptoms of obstructive sleep apnea are improved; and,

2. Objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner.

Adherence to therapy is defined as use of PAP ≥4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. If the above criteria are not met, continued coverage of a PAP device and related accessories will be denied as not reasonable and necessary. If the treating practitioner re-evaluation does not occur until after the 91st day but the evaluation demonstrates that the beneficiary is benefiting from PAP therapy as defined in criteria 1 and 2 above, continued coverage of the PAP device will commence with the date of that re-evaluation.

Beneficiaries who fail the initial 12 week trial are eligible to re-qualify for a PAP device but must have both:

  • In-person clinical re-evaluation by the treating practitioner to determine the etiology of the failure to respond to PAP therapy; and,
  • Repeat sleep test in a facility-based setting (Type 1 study). This may be a repeat diagnostic, titration or split-night study.

If an E0601 device is tried and found ineffective during the initial facility-based titration or home trial, substitution of an E0470 does not change the length of the trial unless there is less than 30 days remaining in the trial period. If more than 30 days remain in the trial period, the clinical re-evaluation would still occur between the 31st and 91st day following the initiation of an E0601 and objective documentation of adherence on the E0470 would need to occur prior to the 91st day following initiation of the E0601. If less than 30 days remain in the trial period, the clinical re-evaluation and objective documentation of adherence must occur before the 120th day following the initiation of the E0601.

If an E0601 device was used for more than 3 months and the beneficiary was then switched to an E0470, the clinical re-evaluation must occur between the 31st and 91st day following the initiation of the E0470. There would also need to be documentation of adherence to therapy during the 3 month trial with the E0470. If there is discontinuation of usage of a PAP device at any time, the supplier is expected to ascertain this and stop billing for the equipment and related accessories and supplies. For a PAP device dispensed prior to November 1, 2008, if the initial Medicare coverage criteria in effect at the time were met and the criteria for coverage after the first 3 months that were in effect at the time were met, the device will continue to be covered for dates of service on or after November 1, 2008 as long as the beneficiary continues to use the device. CONCURRENT USE OF OXYGEN WITH PAP THERAPY: Some beneficiaries may require the simultaneous use of home oxygen therapy and oxygen equipment with a PAP device. To be considered for simultaneous coverage, all requirements in the "Coverage Indications, Limitations and/or Medical Necessity" sections of both the Oxygen and Oxygen Equipment and Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea LCDs must be met. Consequently, in addition to this LCD, suppliers should refer to the Oxygen and Oxygen Equipment LCD and related Policy Article for additional coverage, coding and documentation requirements. For beneficiaries with OSA to be considered for oxygen therapy and oxygen equipment, the OSA must be sufficiently treated such that the underlying condition resulting in hypoxemia is unmasked. This must be demonstrated before oxygen saturation results obtained during polysomnography are considered qualifying for oxygen therapy and oxygen equipment.

For beneficiaries with OSA, a qualifying oxygen saturation test for the purposes of Medicare home oxygen and oxygen equipment reimbursement may only occur during a titration polysomnographic study (either split-night or stand-alone). The titration PSG is one in which all of the following criteria are met:

      1. The titration is conducted over a minimum of two (2) hours; and,

      2. During titration:

A. The AHI/RDI is reduced to less than or equal to an average of ten (10) events per hour; or,

B. If the initial AHI/RDI was less than an average of ten (10) events per hour, the titration demonstrates further reduction in the AHI/RDI; and,

  • Nocturnal oximetry conducted for the purpose of oxygen and oxygen equipment reimbursement qualification may only be performed after optimal PAP settings have been determined and the beneficiary is using the PAP device at those settings; and,
  • The nocturnal oximetry conducted during the PSG demonstrates an oxygen saturation of ≤ 88%.

To be eligible for Medicare coverage and payment for home oxygen therapy and oxygen equipment for concurrent use with PAP therapy, the beneficiary must meet all other coverage requirements for oxygen therapy and oxygen equipment. Beneficiaries that qualify for oxygen therapy based on testing conducted only during the course of a sleep test are eligible only for reimbursement of stationary equipment.

Overnight oximetry performed as part of home sleep testing or as part of any other home testing is not considered as eligible to be used for qualification for reimbursement of home oxygen and oxygen equipment (see the "Overnight Oximetry Studies" section of the Oxygen and Oxygen Equipment LCD for additional information).

REPLACEMENT: This section applies to PAP devices initially provided and covered while the beneficiary was in Medicare fee-for-service (FFS). If a PAP device is replaced during the 5 year reasonable useful lifetime (RUL) because of loss, theft, or irreparable damage due to a specific incident, there is no requirement for a new clinical evaluation, sleep test, or trial period. If a PAP device is replaced following the 5 year RUL, there must be an in-person evaluation by their treating practitioner that documents that the beneficiary continues to use and benefit from the PAP device. There is no requirement for a new sleep test or trial period.

BENEFICIARIES ENTERING MEDICARE:

For beneficiaries who received a PAP device prior to enrollment in fee for service (FFS) Medicare and are seeking Medicare coverage of either rental of the device, a replacement PAP device and/or accessories, both of the following coverage requirements must be met:

  • Sleep test - There must be documentation that the beneficiary had a sleep test, prior to FFS Medicare enrollment, that meets the Medicare AHI/RDI coverage criteria in effect at the time that the beneficiary seeks Medicare coverage of a replacement PAP device and/or accessories; and,
  • Clinical Evaluation - Following enrollment in FFS Medicare, the beneficiary must have an in-person evaluation by their treating practitioner who documents in the beneficiary’s medical record that:

         A. The beneficiary has a diagnosis of obstructive sleep apnea; and,

         B. The beneficiary continues to use the PAP device.

If either criteria 1 or 2 above are not met, the claim will be denied as not reasonable and necessary. In these situations, there is no requirement for a clinical re-evaluation or for objective documentation of adherence to use of the device.

ACCESSORIES: Accessories used with a PAP device are covered when the coverage criteria for the device are met. If the coverage criteria are not met, the accessories will be denied as not reasonable and necessary. The following table represents the usual maximum amount of accessories expected to be reasonable and necessary:

Quantities of supplies greater than those described in the policy as the usual maximum amounts will be denied as not reasonable and necessary. GENERAL

A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving a completed SWO, the claim shall be denied as not reasonable and necessary.

For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) base items that require a Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO before the DMEPOS item is delivered to a beneficiary. If a supplier delivers a DMEPOS item without first receiving a WOPD, the claim shall be denied as not reasonable and necessary. Refer to the LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.

For DMEPOS base items that require a WOPD, and also require separately billed associated options, accessories, and/or supplies, the supplier must have received a WOPD which lists the base item and which may list all the associated options, accessories, and/or supplies that are separately billed prior to the delivery of the items. In this scenario, if the supplier separately bills for associated options, accessories, and/or supplies without first receiving a completed and signed WOPD of the base item prior to delivery, the claim(s) shall be denied as not reasonable and necessary.

An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC articles. Claims that do not meet coding guidelines shall be denied as not reasonable and necessary/incorrectly coded.

Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. Proof of delivery documentation must be made available to the Medicare contractor upon request. All services that do not have appropriate proof of delivery from the supplier shall be denied as not reasonable and necessary.

REFILL REQUIREMENTS For DMEPOS items and supplies provided on a recurring basis, billing must be based on prospective, not retrospective use. For DMEPOS products (A4604, A7027 , A7028, A7029, A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7044, A7045, A7046) that are supplied as refills to the original order, suppliers must contact the beneficiary , and document an affirmative response, prior to dispensing the refill and not automatically ship on a pre-determined basis, even if authorized by the beneficiary. This shall be done to ensure that the refilled item remains reasonable and necessary, existing supplies are expected to end, and to confirm any changes or modifications to the order. Contact with the beneficiary or designee regarding refills must take place no sooner than 30 calendar days prior to the expected end of the current supply.  For delivery of refills, the supplier must deliver the DMEPOS product no sooner than 10 calendar days prior to the expected end of the current supply. This is regardless of which delivery method is utilized. For all DMEPOS items that are provided on a recurring basis, suppliers are required to have contact with the beneficiary or caregiver/designee and document an affirmative response, prior to dispensing a new supply of items. Suppliers must not deliver refills without a refill request and an affirmative response from a beneficiary. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary. Suppliers must not dispense a quantity of supplies exceeding a beneficiary's expected utilization. Suppliers must stay attuned to changed or atypical utilization patterns on the part of their clients. Suppliers must verify with the treating practitioners that any changed or atypical utilization is warranted. Regardless of utilization, a supplier must not dispense more than a three (3) - month quantity at a time. Either a non-heated (E0561) or heated (E0562) humidifier is covered when ordered by the treating practitioner for use with a covered PAP (E0470 or E0601) device.

Proposed Process Information

Coding information, bill type codes, revenue codes, cpt/hcpcs codes.

The appearance of a code in this section does not necessarily indicate coverage. HCPCS MODIFIERS: EY - No physician or other licensed health care provider order for this item or service GA - Waiver of liability statement issued as required by payer policy, individual case GZ - Item or service expected to be denied as not reasonable and necessary KX - Requirements specified in the medical policy have been met HCPCS CODES: EQUIPMENT:

ACCESSORIES

ICD-10-CM Codes that Support Medical Necessity

Icd-10-cm codes that do not support medical necessity, additional icd-10 information, general information.

DOCUMENTATION REQUIREMENTS Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider". It is expected that the beneficiary's medical records will reflect the need for the care provided. The beneficiary's medical records include the treating practitioner's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request. GENERAL DOCUMENTATION REQUIREMENTS

In order to justify payment for DMEPOS items, suppliers must meet the following requirements:

Medical Record Information (including continued need/use if applicable)

Correct Coding

Proof of Delivery

Refill Documentation

Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this policy under the Related Local Coverage Documents section for additional information regarding these requirements. Refer to the Supplier Manual for additional information on documentation requirements. Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD. POLICY SPECIFIC DOCUMENTATION REQUIREMENTS Items covered in this LCD have additional policy-specific requirements that must be met prior to Medicare reimbursement. Refer to the LCD-related Policy article, located at the bottom of this policy under the Related Local Coverage Documents section for additional information. Miscellaneous Appendices APPENDIX A: EPWORTH SLEEPINESS SCALE How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation: 0 = would never doze or sleep. 1 = slight chance of dozing or sleeping 2 = moderate chance of dozing or sleeping 3 = high chance of dozing or sleeping

0-9 – Average score, normal population Epworth Sleepiness Scale reprinted with permission of the Associated Professional Sleep Societies ( Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991;14(6):540-545 ). Utilization Guidelines Refer to Coverage Indications, Limitations, and/or Medical Necessity

Revision History Information

Associated documents.

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Page Help for LCD - Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L33718)

Introduction.

This page displays your requested Local Coverage Determination (LCD). The document is broken into multiple sections. You can use the Contents side panel to help navigate the various sections. A Local Coverage Determination (LCD) is a decision made by a Medicare Administrative Contractor (MAC) on whether a particular service or item is reasonable and necessary, and therefore covered by Medicare within the specific jurisdiction that the MAC oversees. Please note that codes (CPT/HCPCS and ICD-10) have moved from LCDs to Billing & Coding Articles.

More information

MACs are Medicare contractors that develop LCDs and process Medicare claims. MACs develop an LCD when there is no national coverage determination (NCD) or when there is a need to further define an NCD for the specific jurisdiction. LCDs outline how the contractor will review claims to ensure that the services provided meet Medicare coverage requirements. Before an LCD becomes final, the MAC publishes Proposed LCDs, which include a public comment period. LCD document IDs begin with the letter "L" (e.g., L12345). Proposed LCD document IDs begin with the letters "DL" (e.g., DL12345). The guidelines for LCD development are provided in Chapter 13 of the Medicare Program Integrity Manual. The Social Security Act, Sections 1869(f)(2)(B) and 1862(l)(5)(D) define LCDs and provide information on the process

The LCD Tracking Sheet is a pop-up modal that is displayed on top of any Proposed LCD that began to appear on the MCD on or after 1/1/2022. The Tracking Sheet provides key details about the Proposed LCD, including a summary of the issue, who requested the new/updated policy, links to key documents, important process-related dates, who to contact with questions about the policy, and the history of previous policy considerations. The information displayed in the Tracking Sheet is pulled from the accompanying Proposed LCD and its correlating Final LCD and will be updated as new data becomes available. The Tracking Sheet modal can be closed and re-opened when viewing a Proposed LCD.

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Frequently Asked Questions (FAQs)

Are you a provider and have a question about billing or coding.

Please contact your Medicare Administrative Contractor (MAC). MACs can be found in the MAC Contacts Report .

Do you have questions related to the content of a specific Local Coverage Determination (LCD) or an Article?

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For the most part, codes are no longer included in the LCD (policy). You will find them in the Billing & Coding Articles. Try using the MCD Search to find what you're looking for. Enter the code you're looking for in the "Enter keyword, code, or document ID" box. The list of results will include documents which contain the code you entered.

Please Note: For Durable Medical Equipment (DME) MACs only, CPT/HCPCS codes remain located in LCDs. All other Codes (ICD-10, Bill Type, and Revenue) have moved to Articles for DME MACs, as they have for the other Local Coverage MAC types.

National Coverage

NCDs do not contain claims processing information like diagnosis or procedure codes nor do they give instructions to the provider on how to bill Medicare for the service or item. For this supplementary claims processing information we rely on other CMS publications, namely Change Requests (CR) Transmittals and inclusions in the Medicare Fee-For-Service Claims Processing Manual (CPM).

In order for CMS to change billing and claims processing systems to accommodate the coverage conditions within the NCD, we instruct contractors and system maintainers to modify the claims processing systems at the national or local level through CR Transmittals. CRs are not policy, rather CRs are used to relay instructions regarding the edits of the various claims processing systems in very descriptive, technical language usually employing the codes or code combinations likely to be encountered with claims subject to the policy in question. As clinical or administrative codes change or system or policy requirements dictate, CR instructions are updated to ensure the systems are applying the most appropriate claims processing instructions applicable to the policy.

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AirMini AutoSet Travel Auto-CPAP Machine Package

Contact us for information & alternatives.

One of the smallest CPAPs in the world is also one of the most advanced. AirMini brings ResMed's proven AutoSet Auto-CPAP algorithms, industry leading EPR comfort technologies, and unmatched design and quality to a truly portable Auto-CPAP. It's quiet and small and weighs just 10.6 ounces!

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Small & Portable: Great for Home & Travel:  Resmed's AirMini is more than just an ultra portable Auto-CPAP machine, it's a turn-key solution for sleep therapy at home or on the go. AirMini Auto includes ResMed's advanced Autoset and AutoSet For Her breathing algorithms that provide effective therapy at the lowest pressure levels all night long. The AutoSet algorithm monitors your breathing and, when it detects flow limitations, it gently increases pressure until the event has cleared. After an event AutoSet decreases pressure again to improve overall sleep comfort.

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HumidX Effective Waterless Humidification: Leave your distilled water at home and still get the benefits of humidification! AirMini’s HumidX & HumidX Plus Heat Moisture Exchanging (HME) Humidifying Filters provide the comfort of humidification without the bulk hassle of your typical water based humidifier systems. The HumidX Humidifying Filters work by capturing the moisture from exhaled heat and stores it in the HME prior to reaching your masks vents. When you inhale the HumidX HME releases the humidity back into your therapy stream for portable, waterless and effective humidification.

  • HumidX HME Humidifiers are exclusively compatible with the following AirMini Mask Setup Packs: AirFit and AirTouch N20 & N30 Nasal, F20 Full Face, and P10 Nasal Pillow.
  • HumidX: Use standard HumidX HMEs for most climates and sleep environments.
  • HumidX Plus: Use HumidX Plus for dry and high altitude environments, like aircraft, where humidity is low.

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Enhanced Compliance with Bluetooth & the AirMini App: Manage your sleep therapy and comfort settings with ease when you download the free AirMini App for iOS and Android. You can also track your therapy progress directly on your phone or tablet! With a simple push of a button the sophisticated AirMini App syncs data wirelessly, via a Bluetooth connection, so you can review your score each morning as well as access the previous 30 days of sleep data too. Using the AirMini App is a great way to stay on top of your sleep therapy!

SmartStart & Auto Stop Convenience: The AirMini’s SmartStart function starts your sleep apnea therapy as soon as you breathe into your mask. If you remove your mask, the therapy will stop after just a few seconds. You also have the option to stop your therapy on your own if you prefer, AirMini lets you do that with just a touch of a button.

Expiratory Pressure Relief: ResMed's Expiratory Pressure Relief feature will reduce the work of breathing during exhalation and provide a gentle pressure that naturally adapts to your breathing cycle throughout the night. You can turn off the Expiratory Pressure Relief or choose levels from 1 to 3, 1 being the minimum pressure relief and 3 being the maximum.

AutoRamp with Sleep Onset Detection: AirMini’s AutoRamp feature with sleep onset detection helps make your sleep therapy comfortable from the moment you turn on your device. The AutoRamp feature works by delivering a lower pressure setting to help you fall asleep easier. Once the device detects that you’re asleep, it comfortable ramps up the pressure to ensure the device is delivering your prescribed pressure setting. If you prefer a set ramp time or want the auto ramp turned off all together, you can simply do that too. Comfort settings are easy with the AirMini App!

FAA Approved for Use on Commercial Flights: The AirMini is great for home, but it is FAA approved and built for travel as well. You can slide it into your overnight bag and head out the door, or better yet upgrade with a custom fit AirMini Premium Travel Bag for added protection and convenience.

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COMMENTS

  1. HCPCS Codes

    CPAP/BiPAP Machine Insurance (HCPCS) Codes. E0601: Continuous airway pressure (CPAP/APAP) device: E0470: Respiratory assist device, bi-level pressure (BiPAP) capability, WITHOUT backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

  2. Common HCPCS Insurance Codes & ICD 10 Diagnosis Codes for Sleep, Oxyge

    CPAP/BiPAP MACHINE INSURANCE (HCPCS) CODES: E0601: Continuous airway pressure (CPAP/APAP) device: E0470: Respiratory assist device, bi-level pressure (BiPAP) capability, WITHOUT backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) E0471

  3. What are the HCPCS, CPT or billing codes related to CPAP, Sleep Apnea

    Every medical product or service has a CPT (Current Procedural Terminology) code assigned to it. Government healthcare providers use HCPCS (Healthcare Common Procedure Coding System) which are generally the same as the CPT codes. Frequently the CPT or HCPCS codes are referred to a "billing codes".

  4. Miscellaneous HCPCS (A9999 and E1399)

    You can use the following codes to request miscellaneous CPAP-related supplies: A9999 for accessories. E1399 for device-related supplies. Client services representatives and Faith (the interactive voice response system) don't typically ask patients if they require miscellaneous supplies during outreach. However, these codes allow you to offer ...

  5. Article

    For auto-titrating single-level CPAP devices use HCPCS code E0601. A bi-level respiratory assist device without backup rate (E0470) allows independent setting of inspiratory and expiratory pressures to deliver positive airway pressure within a single respiratory cycle by way of tubing and a noninvasive interface (such as a nasal, oral, or ...

  6. PDF CPAP technology designed for success

    CPAP patients who use ResMed ClimateLineAir heated ... HCPCS codes Air11 Travel Bag 39221 Air11 Filter, STD 1 pack 39300 A7038 Air11 Filter, ... HCPCS codes AirSense 11 AutoSet USA CO 39000 E0601 + E0562 + A7037 + A9279 AirSense 11 AutoSet USA TRI 39001 E0601 + E0562 + A4604 + A9279

  7. PDF 2024 Medicare fee schedule and Healthcare Common Procedure ...

    Continuous positive airway pressure (CPAP) device. Includes automatic CPAP devices. All Air10 & Air11 devices CR† 1x per 5 yrs. $43 - $58 $47 - $50 $83 - $93 A9279 Monitoring feature/device, stand-alone or integrated, any type, includes all accessories, components and electronics, not otherwise classified All Air10 & Air11 devices

  8. PDF HELPFUL HINTS FOR FILING

    Note: Inclusion or exclusion of a code for a specific product or supply does not imply any health insurance coverage or reimbursement policy. All referenced information an d codes were taken from HCPCS. Please refer to DMEPOS Supplier Manual for complete explanations. Customer Service: 1-800-345-6443 • 724-387-4000

  9. CPAP Insurance Codes

    Below are the codes used for submission on insurance claim forms. E0601 NU: CPAP Device Purchase. E0470 NU: BiPAP without back-up rate feature. E0471 NU: BiPAP with back-up rate feature. A7030: Full face mask. A7031: Full face mask cushion. A7034: Nasal mask (mask or cannula type) used with CPAP device with or without head strap.

  10. How to Bill Your Insurance for CPAP Supplies

    CPAP, Bi-Level, Bi-PAP MACHINE INSURANCE (HCPCS) CODES. E0601 - Continuous airway pressure (CPAP/APAP) device. E0470 - Respiratory assist device, Bi-Level pressure (Bi-PAP) capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

  11. Sleep Medicine Codes

    G Codes (home sleep apnea testing) The G codes (G0398, G0399 and G0400), which describe home sleep apnea testing (HSAT) services, were added to the Healthcare Common Procedure Coding System (HCPCS) Level II in 2008. Some insurers accept the G codes while others accept the CPT® codes for HSATs (95800, 95801 and 95806).

  12. CPAP Billing Codes

    CPAP/Bi-PAP MACHINE INSURANCE (HCPC) CODES. E0601. Continuous airway pressure (CPAP/APAP) device. E0470. Respiratory assist device, bi-level pressure (Bi-PAP) capability, WITHOUT backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) E0471.

  13. What are the Insurance Codes for CPAP Machines and Equipment?

    Below is a detailed list of codes your insurance company may need to quickly process your claim. E0601 - CPAP Machine Purchase. A7034 - CPAP Nasal Mask. A7032 - CPAP Nasal Mask Cushion. A7030 - CPAP Full Face Mask. A7031 - CPAP Full Face Mask Cushion. A7044 - CPAP Full Oral Interface. A7046 - CPAP Humidifier Chamber.

  14. What Are HCPCS Codes For CPAP?

    Below are the list of HCPCS codes For BiPAP/ CPAP Mask Coverage. HCPCS CODE: A7030. Positive Airway Pressure (BiPAP, APAP, CPAP) equipment with a Full Face Mask. HCPCS CODE: A7034. With or without a head strap, a nasal interface (mask or cannula type) is used with positive airway pressure (CPAP/BiPAP/APAP) equipment. HCPCS CODE: A7044.

  15. : Common HCPCS Insurance Codes & ICD 10 Diagnosis Codes for Sleep

    CPAP/BiPAP MACHINE INSURANCE (HCPCS) CODES: E0601: Continuous airway pressure (CPAP/APAP) device: E0470: Respiratory assist device, bi-level pressure (BiPAP) capability, WITHOUT backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

  16. HCPCS Insurance Billing Codes

    In an effort to assist out customers in filing a claim we are providing a list of the most common HCPCS codes used for sleep therapy and oxygen therapy equipment and supplies. CPAP/BiLevel Michine HCPCS Codes: E0601 Continuous airway pressure device (CPAP/APAP) E0470 Respiratory assist device, bi-level pressure capability, without backup rate ...

  17. Continuous positive airway pressure (CPAP) device E0601

    Codes. HCPCS. HCPCS Codes. Durable Medical Equipment E0100-E8002. Humidifiers and Nebulizers with Related Equipment E0550-E0601. Continuous positive airway pressure (CPAP) device. E0600. E0601. E0602.

  18. PDF AirMini Fast Facts

    Most payors cover CPAP devices, if the coverage criteria are met and medical necessity is established. While patients may seek health insurance reimbursement for AirMini, payors may or may not cover secondary devices. If the payor determines AirMini is not medically necessary the patient may choose to pay cash.

  19. Insurance Codes

    Below are the HCPCS codes you may need for the claim form: HCPCS CODES. CPAP/BiPAP MACHINE. E0601- Continuous airway pressure (CPAP/APAP) device. E0470- Respiratory assist device, bi-level pressure (BiPAP) capability, WITHOUT backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with ...

  20. E0601

    Continuous positive airway pressure (cpap) device. Durable Medical Equipment (DME) E0601 is a valid 2024 HCPCS code for Continuous positive airway pressure (cpap) device or just " Cont airway pressure device " for short, used in Rental of DME .

  21. LCD

    HCPCS CODES: EQUIPMENT: Group 1 Codes. Code Description; ... (CPAP) DEVICE Group 2 (19 Codes) Group 2 Paragraph. ACCESSORIES. Group 2 Codes. Code Description; A4604 TUBING WITH INTEGRATED HEATING ELEMENT FOR USE WITH POSITIVE AIRWAY PRESSURE DEVICE A7027 COMBINATION ORAL/NASAL MASK, USED WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE, EACH ...

  22. AirMini AutoSet Travel Auto-CPAP Machine Package

    AirMini Auto-CPAP Machine, Drawstring Travel Bag, Universal Power Supply with Cord, Starter Filter & Printed User Manual ... HCPCS Code: Not Applicable Warranty: 2-Year GTIN / UPC Code: 00619498381012 Compatibility: ResMed P10 Pillow, N20 & N30 Nasal, and F20 & F30 Series Full Face AirFit & AirTouch Masks. In each case a special mask setup pack ...

  23. Reimbursement resources

    For example, "Spoke to beneficiary, and she states that as of 12/01/14, there are 650 hours on her continuous positive airway pressure (CPAP) machine. She states that she uses the CPAP every night, and it is very beneficial." On 11/01/14, the beginning reading was 500 hours. This calculates to 5 hours per night for 30 days.