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February 16, 2023

Best Practices for Billing PAP/RAD Accessories

For accessories used with current capped rental and beneficiary owned equipment, append the KX modifier to any claim line where the Coverage Indications, Limitations, and/or Medical Necessity” section of the related Local Coverage Determination (LCD) criteria have been met.

Prior to submitting the claim, make sure the claim is not billed for multiple HCPCS codes that provide the same function. For example:

  • A claim with HCPCS code A7037 (tubing) and A4604 (tubing with heated element) will have both codes denied because they provide the same function.
  • If you bill multiple masks (A7027, A7030, or A7034) on the same claim, both masks will be denied.

Keep in mind that someone other than the treating practitioner can complete the standard written order (SWO) for these accessories. As such, you can create the SWO based on the specific accessories provided to the Medicare beneficiary at initial set-up. Send the order to the ordering practitioner for review and signature.

Also, remember to add the information below to the first claim for PAP/RAD accessories on beneficiary-owned equipment. Chapter 5, Section 8, of the Supplier Manual outlines the information we need to ensure the DMEPOS item is on file so future accessory claims can pay. Provide the following information for these claims:

  • HCPCS code of the base equipment (such as "E0601" or "E0470")
  • A notation the equipment is beneficiary-owned (such as "bene-owned")
  • Date the beneficiary obtained the equipment (such as "07/2019")

Here’s an example of notations in the NTE segment for a beneficiary that began RAD therapy prior to Medicare enrollment, and the supplier is filing claims for accessories only: "E0471, bene-owned, received device 10/19, paid by United Healthcare." Adding notes like this is helpful for discerning between PAP (E0601) and RAD (E0470 or E0471) accessories.

Lastly, be sure to check for overutilization and same/similar equipment prior to billing. Another supplier could be billing for the accessories, the beneficiary doesn't recall when they got their last mask, etc. Use the myCGS online portal to check the prior billing of PAP accessory HCPCS codes.

Originally published January 30, 2019. Revised February 2023.


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