Important PAP Policy Reminders

Important PAP Policy Reminders

Ø  Using the Correct ICD-9 Code:

When billing for a PAP device either the E0601 or E0470 under the PAP policy, be sure to use the correct diagnosis code.  The only covered diagnosis under the PAP medical policy is obstructive sleep apnea (OSA) which is ICD-9 code 327.23.    If you are supplier billing claims in Jurisdiction B, effective April 1, 2014, suppliers will start to have claims rejected when using the incorrect ICD-9 code.  The claim will reject with ANSI code CO-4 which is procedure code is inconsistent with the modifier used, or a required modifier is missing.

Remember the PAP medical policy does state that the only covered ICD-9 code is 327.23; this applies to all four Jurisdictions.

Before submitting the claim to Medicare for processing, be sure to review all the elements making sure it’s a “clean claim”.

Ø  Liners Used with PAP Mask:

A liner that is placed between the PAP mask and the patient’s skin is considered a comfort or convenience item.   This liner is a non covered item or service (A9270) which means no additional payment.  Liners are not considered as an interface.

Ø  Qualifying for Oxygen When PAP Device Involved:

If a patient with OSA needs home oxygen to be bled in at night for use with the PAP device, the only way to qualify the patient is through a sleep facility during a polysomnography, titration, or split night study.  The reason is to make sure the patient is in a chronic stable state while using the optimal pressure on the PAP device prior to considering initiation of oxygen therapy.  In addition, the patient needs to meet all the oxygen coverage criteria including a diagnosis of a severe lung disease or hypoxia related symptom.  Remember hypoxia alone will not be enough fora diagnosis; need to know what is causing the hypoxia.

The following are the testing requirements when performed in sleep facility:

  1. The titration is conducted over a minimum of two (2) hours; and,
  2. During titration:
    1. The AHI/RDI is reduced to less than or equal to an average of ten (10) events per hour; or,
    2. 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,
  3. Nocturnal oximetry conducted for the purpose for oxygen 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,
  4. The nocturnal oximetry conducted during the PSG demonstrates an oxygen saturation = 88% for 5 minutes total (which need not be continuous).

Overnight oximetry performed in the home setting under these circumstances is not considered eligible as a qualification for home oxygen therapy.

For more information or questions, please contact Ronda Buhrmester, Reimbursement Specialist, at 888-665-6518 or email ronda.buhrmester@vgm.com