Supplies Associated with Continuous Positive Airway Pressure (CPAP) or Bi-level Positive Airway Pressure (BIPAP)

Reimbursement Policy:

Supplies Associated with Continuous Positive Airway Pressure (CPAP) or Bi-level Positive Airway Pressure (BIPAP)

Effective Date:

January 1, 2013

Purpose:

This policy provides guidelines for reimbursement of supply codes associated with the Continuous Positive Airway Pressure or Bi-level Positive Airway Pressure (CPAP/BIPAP) to participating and nonparticipating providers.

Products:

All products are included except for products where Horizon is secondary to Medicare (e.g. Medigap).

All Insured and ASO accounts are included.

POLICY:

Many CPAP/BIPAP supplies associated with sleep therapy are designed to be disposable. Masks, tubing, filters and headgear are not designed to last extreme amounts of time.

Using the recommended replacement schedule for CPAP/BIPAP supplies from CMS/Medicare as a guideline, this policy defines when the submission of an associated CPAP/BIPAP supply is being submitted at a rate that exceeds the recommended replacement schedule and is for use with equipment that meets the criteria of Horizon BCBSNJ’s medical policy.

CPAP/BIPAP supplies may only be reimbursed when used with equipment that meets the criteria of Horizon BCBSNJ’s Medical Management of Obstructive Sleep Apnea Syndrome medical policy.

CPAP/BIPAP supplies may only be dispensed per the order of a physician or other licensed health care provider.

The following sources were used as guidelines in determining the frequency of the reimbursement for the supplies associated with CPAP/BIPAP in this policy. CMS Local Coverage Determination Policies:

• LCD11528 NHIC, Corp.
• LCD11518 Cigna Government Services.
• LCD171 Noridian Administrative Services.
• LCD27230 National Government Services, Inc.

Limitations and Exclusions:

While reimbursement is considered, payment determination is subject to, but not limited to:

• Group benefit.
• Provider contract.
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity.
• Mandated or legislative required criteria will always supersede.

Other exclusions include:

• COB and Medicare claims where Horizon is secondary.
• ITS Home PAR.
• ITS Host Medicare Advantage.
• FEP.

Procedures:

CPAP/BIPAP supplies being dispensed for use with equipment that meets the criteria of Horizon BCBSNJ’s medical policy for Medical Management of Obstructive Sleep Apnea Syndrome AND have an order on file from a physician or licensed health care provider must be submitted with modifier KX in order to be considered for reimbursement. If there is no current order on file from a physician or licensed health care provider, claim lines must be submitted with modifier EY.

Modifier Descriptions:

KXRequirements specified in the Horizon-BCBSNJ medical policy for CPAP equipment have been met.

EY/td>No physician or licensed health care provider order for this item or service.

Claim lines containing CPAP/BIPAP supply codes submitted without modifier KX will be denied.

Supplies related to equipment that does not meet the criteria defined in Horizon-BCBSNJ’s medical policy Medical Management of Obstructive Sleep Apnea Syndrome will not be reimbursed.

Claim lines containing CPAP/BIPAP supply codes submitted with modifier EY will also be denied.

CPAP/BIPAP Supplies may only be dispensed per the order of a physician or other licensed health care provider.

Supply codes associated with the Continuous Positive Airway Pressure or Bi-level Positive Airway Pressure (CPAP/BIPAP) therapy will not be reimbursed at a frequency that exceeds the usual or customary frequency shown in the following table.

ProcedureQuantityDays

A4604190

A7027190

A7028230

A7029230

A7030190

A7031130

A7032230

A7033230

A7034190

A70351180

A70361180

A7037190

A7038230

A70391180

A70461180

Example: Procedure A7030 is allowed quantity = 1 every 90 days.

MESSAGES:

1. Denial due to lack of modifier KX

   U627This service is not paid. This supply is not paid because the required modifier is missing. Please refer to reimbursement policy for CPAP/BIPAP supplies.

2. Denial based on modifiers –EY

   U626This service is not paid. This supply is not paid because the modifier submitted on the claim was ineligible. Please refer to reimbursement policy for CPAP/BIPAP supplies.

3. Denial that exceeds frequency

   U624This service is not paid. This supply exceeds the number of units allowed within the time period. Please refer to the CPAP/BIPAP supply reimbursement policy.

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