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CGS Administrators, LLC

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January 30, 2019

Billing Reminder – PAP/RAD Accessories

CGS staff has noticed some recent trends in billing accessories for Positive Airway Pressure (PAP) Devices and Respiratory Assist Devices (RAD), both for current capped rentals and with beneficiary-owned equipment.  This article is a reminder of some best practices to follow when billing CGS for PAP and RAD accessories. For new/current capped rentals and accessories claims, be sure to append the KX modifier to any claim line where the Local Coverage Determination criteria have been met and the PAP/RAD and related accessories are medically necessary. 

Prior to submitting your claim, ensure that you are not billing 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 physician can complete the detailed written order for these accessories.  As such, you can create the DWO based on the specific accessories provided to the Medicare beneficiary at initial set-up.  Send the order to the ordering physician for review, signature and date.

We also continue to see many claims each month for PAP/RAD accessories only on beneficiary-owned equipment.  Please remember to add the information below to the claim narrative (NTE segment) on the first accessories claim so we can process the claim efficiently and effectively for you.  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.   Please provide the following information for these claims:

Here is 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 10/17, paid by United Healthcare.”    Adding these notes is especially important to discern between PAP (E0601) and RAD (E0470 or E0471) accessories.

One final reminder we wanted to share is this: remember to check for overutilization and same/similar equipment prior to billing.  There could be another supplier billing for the accessories or the beneficiary doesn’t recall when they got their last mask, etc.  The Claims History section of our web portal, myCGS, can be used to check the prior billing of PAP accessory HCPCS codes.

This list of CGS resources is available to help you before you bill your PAP/RAD accessory claims to CGS:

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