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BiPAP auto SV Advanced For patients with central or complex sleep apnea and periodic breathing HCPCS Code E0470 and E0471
Overview The following information describes the Durable Medical Equipment Medicare Administrative Contractors’ (DME MAC) medical policies for respiratory assist devices related to central and complex apnea and periodic breathing. Information was obtained from the DMEPOS supplier manuals and local coverage determinations from each jurisdiction. Coding, coverage, payment and documentation information are to be used as a guide. For specific instructions, please reference your supplier manual, or contact your DME MAC medical director or provider helpline. For an item to be covered by Medicare, it must: 1. Be eligible for 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 3. Meet all other applicable Medicare statutory and regulatory requirements.1 All Medicare coverage, coding and documentation requirements must be met. General coverage guidelines
Documentation
If at any time the patient discontinues use of E0470 or E0471, the supplier is expected to ascertain this and discontinue billing for the equipment and related accessories and supplies.
Refer to your DME MAC jurisdiction supplier manual for specific dispensing requirements, including written order prior to delivery requirements and face-to-face visit requirements.
The treating physician must fully document in the patient’s medical record the symptoms characteristic of sleep-associated hypoventilation, such as daytime hypersomnolence, excessive fatigue, morning headache, cognitive dysfunction, dyspnea, etc.
1
Section 1862(a)1(A) of Title XVIII of the Social Security Act.
Central sleep apnea or complex sleep apnea Note: The following flow chart illustrates the clinical guidelines for coverage. For the documentation requirements for continued coverage, refer to the documentation section on page 4. Prior to initiating therapy, a complete facilitybased, attended PSG must be performed documenting the following criteria:
Criterion A The diagnosis of central sleep apnea (CSA) or complex sleep apnea (CompSA). AND
Central sleep apnea is defined as: 1. An Apnea Hypopnea Index (AHI) greater than or equal to 5; and 2. Central apneas/hypopneas greater than 50% of the total apneas/hypopneas; and 3. Central apnea-Central Hypopnea Index (CAHI) greater than or equal to 5 times per hour; and 4. The presence of at least one of the following: • Sleepiness • Difficulty initiating or maintaining sleep, frequent awakenings or non-restorative sleep • Awakening short of breath • Snoring • Witnessed apneas 5. There is no evidence of daytime or nocturnal hypoventilation
Continued coverage beyond the first three months of therapy
Criterion B Significant improvement of the sleep-associated hypoventilation with the use of an E0470 or E0471 device on the settings that will be prescribed for initial use at home, while breathing the patient’s prescribed FlO2.
If all above criteria are met, either an E0470 or E0471 will be covered for the first three months of therapy.
Patients covered for the first three months of an E0470 or an E0471 must be re-evaluated to establish the medical necessity of continued coverage by Medicare beyond the first three months. While the patient may certainly need to be evaluated at earlier intervals after therapy is initiated, the re-evaluation upon which Medicare will base a decision to continue coverage beyond this time must occur no sooner than 61 days after initiating therapy by the treating physician. Medicare will not continue coverage for the fourth and succeeding months of therapy until this re-evaluation has been completed. There must be documentation in the patient’s medical record about the progress of relevant symptoms and patient usage of the device up to that time. Failure of the patient to be consistently using the E0470 or E0471 for an average of 4 hours per 24-hour period by the time of the re-evaluation (on or after 61 days after initiation of therapy) would represent non-compliant utilization for the intended purposes and expectations of benefit. This would constitute reason for Medicare to deny continued coverage as not medically necessary. A signed and dated statement completed by the treating physician no sooner than 61 days after initiating use of the device, declaring that the patient is compliantly using the device (an average of 4 hours per 24-hour period) and that the patient is benefiting from its use, must be obtained by the supplier of the device for continued coverage beyond three months.
Relevant ICD-9/10 diagnosis code
Medicare national average allowables for E0470 and E0471
ICD-9/10 codes Description
HCPCS code
327.21/G47.31
Primary central sleep apnea
E0470
327.22/G47.32
High-altitude periodic breathing
327.27/G47.37
Central sleep apnea in conditions specified elsewhere
E0471
327.29/G47.39
Other organic sleep apnea
BiPAP S/T
786.04/RO6.3
Cheyne-Stokes respiration (Central sleep apnea due to Cheyne-Stokes breathing pattern)*
BiPAP autoSV Advanced
There is no ICD-9 code for complex sleep apnea. Document presence of any central sleep apnea using code above. *BiPAP autoSV Advanced is cleared for the treatment of periodic breathing, such as Cheyne-Stokes respiration.
Allowable per month*
Rental months**
Total allowed
Medicare payment (80%)
Copay (20%)
BiPAP Auto
$182.30
1-3
$546.90
$437.52
$109.38
BiPAP Plus
$136.72
4-13
$1367.20
$1093.76
$273.44
Totals:
$1914.10
$1531.28
$382.82
$454.10
1-3
$1362.30
$1089.84
$272.46
$340.57
4-13
$3405.70
$2724.56
$681.14
Totals:
$4768.00
$3814.40
$953.60
*Allowable per month is based on Jan. 2016 Non-rural (NR) and Rural (R) DMEPOS fee schedule national average, excluding areas subject to competitive bidding. **Rental months 4-13 subject to a 25% reduction from allowed amount; Medicare pays 80% with a 20% patient co-pay.
HCPCS code
Description
Payment category/maximum
E0470 BiPAP Auto and BiPAP Plus
Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask
Capped rental • Rental payment can be made for up to 13 months of continuous use.
E0471 BiPAP S/T and BiPAP autoSV Advanced
Respiratory assist device, bi-level pressure capability, with backup rate feature, used with noninvasive interface, e.g., nasal or facial mask
Capped rental only • Rental payment can be made for up to 13 months of continuous use.
A4604
Tubing with integrated heating element for use with positive airway pressure device
1 per 3 months
A7030
Full face mask used with positive airway pressure device, each
1 per 3 months
A7031
Face mask interface, replacement for full face mask, each
1 per 1 month
A7032
Cushion for use on nasal mask interface, replacement only, each
2 per 1 month
A7033
Pillow for use on nasal cannula type interface, replacement only, pair
2 per 1 month
A7034
Nasal interface (mask or cannula type) used with positive airway pressure device, with or without headstrap
1 per 3 months
A7035
Headgear
1 per 6 months
A7036
Chin strap
1 per 6 months
A7037
Tubing
1 per 3 months
A7038
Filter, disposable
2 per 1 month
A7039
Filter, nondisposable
1 per 6 months
A7045
Exhalation port with or without swivel, replacement only
Not specified in current DME MAC policy
A7046
Water chamber for humidifier, replacement, each
1 per 6 months
A9279
Monitoring feature/device, stand-alone or integrated, any type. Include all accessories. Components and electronics, not otherwise classified.
No current fee schedule allowance; no separate coverage under Medicare
E0561
Humidifier, nonheated
N/A purchase
E0562
Humidifier, heated
N/A purchase
Equipment*
Accessories
*Please note that a –KX modifier is necessary to include when billing E0470 and E0471. The –KX modifier also should be added when billing accessories used with E0470 and E0471.
Documentation requirements An order for the RAD and accessories must be on file with the supplier and available to the DME MAC upon request. This order must be signed and dated by the treating physician. To support continued coverage for a RAD beyond the first three months of therapy, the supplier must obtain the treating physician’s statement (signed and dated). Dispensing orders Equipment and supplies may be delivered upon receipt of a dispensing order except for those items that require a written order prior to delivery. A dispensing order may be verbal or written. The supplier must keep a record of the dispensing order on file. It must contain: • Description of the item • Beneficiary’s name • Prescribing physician’s name • Date of the order and the start date, if the start date is different from the date of the order. • Physician signature (if a written order) or supplier signature (if a verbal order) For the “date of the order” described above, use the date the supplier is contacted by the physician (for verbal orders) or the date entered by the physician (for written dispensing orders). Signature and date stamps are not allowed. Signatures must comply with the CMS signature requirements. The dispensing order must be available upon request. For items that are provided based on a dispensing order, the supplier must obtain a detailed written order before submitting a claim. Written orders prior to delivery ACA 6407 requires a written order prior to delivery (WOPD) for the HCPCS E0470 and E0471, The supplier must have received a complete WOPD that has been both signed and dated by the treating physician and meets the requirements for a detailed written order (DWO) before dispensing the item.
Detailed written orders A DWO is required before billing. Someone other than the ordering physician may produce the DWO. However, the ordering physician must review the content and sign and date the document. It must contain: • Beneficiary’s name • Physician’s name • Date of the order and the start date, if start date is different from the date of the order • Detailed description of the item(s) (see below for selected item) • Physician’s signature and signature date For items provided on a periodic basis the written order must include: • Item(s) to be dispensed • Frequency of use • Quantity to be dispensed • Number of refills For the “Date of the order” described above, use the date the supplier is contacted by the physician (for verbal orders) or the date entered by the physician (for written dispensing orders). Frequency of use information orders must contain detailed instructions for use and specific amounts to be dispensed. Reimbursement shall be based on the specific utilization amount only. Orders that only state “PRN” or “as needed” utilization estimates for replacement frequency, use or consumption are not acceptable. The detailed description in the written order may be either a narrative description or a brand name/model number. Signature and date stamps are not allowed. Signatures must comply with the CMS signature requirements. The DWO must be available upon request. A prescription is not considered as part of the medical record. Medical information intended to demonstrate compliance with coverage criteria may be included on the prescription but must be corroborated by information contained in the medical record.
For more information from Philips Respironics concerning Reimbursement
Customer service
Website
Information and fee schedules Education materials and questions (coding, coverage and payment)
1-800-345-6443; listen to the instructions and follow prompts to select the insurance reimbursement information option
www.philips.com/respironics
This information is for illustrative purposes only. You should not consider this to be either legal or reimbursement advice. Given the rapid and constant change in public and private reimbursement, Philips Healthcare cannot guarantee its comprehensiveness, accuracy, or timeliness. Philips urges you to seek your own counsel and experts for guidance related to reimbursement, including coverage, coding, and payment.
© 2016 Koninklijke Philips N.V. All rights reserved. Specifications are subject to change without notice. Trademarks are the property of Koninklijke Philips N.V. or their respective owners. www.philips.com
Caution: US federal law restricts these devices to sale by or on the order of a physician. edoc MG 1/21/16 MCI 4107265 1010 Murry Ridge Lane, Murrysville, PA 15668 800-345-6443 • 724-387-4000