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What is HCPCS
#1
I thought it would help to post this discussion in the off topic forum because I have read and have participated in a number of discussions where folks are confused over insurance and regulatory requirements that are not directly related to their actual therapy.

Much of this confusion is driven by the language in these billing codes.

These codes are the source of the compliance criteria often quoted out of context in the forum

Objective evidence of adherence to use defined as 4 or more hours per night on 70% of nights during a consecutive 30-day period anytime during the first 3 months of initial use) of the PAP device, reviewed by the treating physician.


HCPCS is an acronym for Healthcare Common Procedure Coding System (HCPCS). Standardized code sets are necessary for Medicare and other health insurance providers to provide healthcare claims that are managed consistently and in an orderly manner. HCPCS Level II coding system is one of several code sets used by healthcare professionals, including medical coders and billers. The Level I HCPCS code set includes CPT® (Current Procedural Terminology) codes. CPT is developed and owned by the American Medical Association (AMA).

The following codes are is used by doctors and DME's in the USA for billing purposes. It is a "one size fits all" conglomeration of requirements that allow them to bill "all payers" using a single code


2013 HCPCS code E0601 and 2016 HCPCS Code: E047: 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)

The treating physician must perform a clinical re-evaluation after the 31st day, but before the 91st day after initiating therapy, which documents the following:

A face-to-face clinical re-evaluation by the treating physician with documentation that symptoms of OSA are improved; and

Objective evidence of adherence to use (defined as use of PAP devices for 4 or more hours per night on 70% of nights during a consecutive 30-day period anytime during the first 3 months of initial use) of the PAP device, reviewed by the treating physician.
NOTE: Documentation of adherence to PAP therapy must be determined through direct download or visual inspection of usage data with written documentation provided in a report to be reviewed by the treating physician and included in the patient’s medical record.
Patients who fail the initial 12-week trial are eligible to re-qualify for a PAP device but must have both:

1. A face-to-face clinical re-evaluation by the treating physician to determine the etiology of the failure to respond to PAP therapy; and
2. A repeat sleep test in a facility-based setting (Type I study).
For patients who received a PAP device prior to enrollment in 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:

1. The patient had a documented sleep test, prior to FFS Medicare enrollment, that meets the Medicare AHI/RDI coverage criteria in effect at the time that the patient seeks Medicare coverage of a replacement PAP device and/or accessories; and
2. The patient had a face-to-face clinical evaluation, following FFS Medicare enrollment, by the treating physician who documented in the patient’s medical record that:
a. The patient has a diagnosis of OSA; and
b.The patient continues to use the PAP device.
If either criterion 1 or 2 above is not met, the claim will be denied as not medically necessary.

The treating physician must perform a clinical re-evaluation after the 31st day, but before the 91st day after initiating therapy, which documents the following:

A face-to-face clinical re-evaluation by the treating physician with documentation that symptoms of OSA are improved; and

Objective evidence of adherence to use (defined as use of PAP devices for 4 or more hours per night on 70% of nights during a consecutive 30-day period anytime during the first 3 months of initial use) of the PAP device, reviewed by the treating physician.
NOTE: Documentation of adherence to PAP therapy must be determined through direct download or visual inspection of usage data with written documentation provided in a report to be reviewed by the treating physician and included in the patient’s medical record.
Patients who fail the initial 12-week trial are eligible to re-qualify for a PAP device but must have both:
1. A face-to-face clinical re-evaluation by the treating physician to determine the etiology of the failure to respond to PAP therapy; and
2. A repeat sleep test in a facility-based setting (Type I study).
For patients who received a PAP device prior to enrollment in 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:
1. The patient had a documented sleep test, prior to FFS Medicare enrollment, that meets the Medicare AHI/RDI coverage criteria in effect at the time that the patient seeks Medicare coverage of a replacement PAP device and/or accessories; and
2. The patient had a face-to-face clinical evaluation, following FFS Medicare enrollment, by the treating physician who documented in the patient’s medical record that:
a.The patient has a diagnosis of OSA; and
b.The patient continues to use the PAP device.
Ordering physician’s legible signature; and Date of the ordering physician’s signature

If either criterion 1 or 2 above is not met, the claim will be denied as not medically necessary.

In these situations, there is no requirement for a clinical re-evaluation or for objective documentation of adherence to use of the device.


I hope this clears thing up Unsure
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#2
Thanks

FFS?
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#3
(07-30-2016, 09:01 PM)green wings Wrote: Thanks

FFS?

Medicare Fee-for-Service (FFS) is a program that provides hospital insurance (Part A) and supplementary medical insurance (Part B) to eligible citizens.

2004-Bon Jovi
it'll take more than a doctor to prescribe a remedy

Observations and recommendations communicated here are the perceptions of the writer and should not be misconstrued as medical advice.
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#4
(07-30-2016, 09:47 PM)0rangebear Wrote:
(07-30-2016, 09:01 PM)green wings Wrote: Thanks

FFS?

Medicare Fee-for-Service (FFS) is a program that provides hospital insurance (Part A) and supplementary medical insurance (Part B) to eligible citizens.

That would not have been my first guess... context is important.
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#5
Thanks. I could have Googled it, I suppose. I think my brain was feeling blitzed after reading all that verbiage.

(07-30-2016, 09:47 PM)0rangebear Wrote:
(07-30-2016, 09:01 PM)green wings Wrote: Thanks

FFS?

Medicare Fee-for-Service (FFS) is a program that provides hospital insurance (Part A) and supplementary medical insurance (Part B) to eligible citizens.

Post Reply Post Reply
#6
I will PM Supersleeper and recommend your post as a Wiki article. Well done!
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#7
Your welcome glad to be helpful


(07-31-2016, 08:57 AM)green wings Wrote: Thanks. I could have Googled it, I suppose. I think my brain was feeling blitzed after reading all that verbiage.

(07-30-2016, 09:47 PM)0rangebear Wrote:
(07-30-2016, 09:01 PM)green wings Wrote: Thanks

FFS?

Medicare Fee-for-Service (FFS) is a program that provides hospital insurance (Part A) and supplementary medical insurance (Part B) to eligible citizens.

2004-Bon Jovi
it'll take more than a doctor to prescribe a remedy

Observations and recommendations communicated here are the perceptions of the writer and should not be misconstrued as medical advice.
Post Reply Post Reply


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