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Positive Airway Pressure for Treatment of Obstructive Sleep Apnea

Revised: 11-09-2016

  • Overview
  • Eligible Providers
  • TPL and Medicare
  • Eligible Recipients
  • Covered Services
  • Recipient Compliance
  • Noncovered Services
  • Authorization
  • Billing
  • Overview

    Continuous Positive Airway Pressure (CPAP) and Bi-level Positive Airway Pressure (Bi-PAP) devices are used for treating obstructive sleep apnea.

    Eligible Providers

    The following providers may provide positive airway pressure (PAP) devices and related supplies:

  • • Medical suppliers
  • • Pharmacies
  • • Home health agencies
  • • Indian Health Services
  • • Federally Qualified Health Centers
  • • Rural Health Clinics
  • TPL and Medicare

    Providers must meet any provider criteria, including accreditation, for third-party insurance or for Medicare to assist recipients for whom MHCP is not the primary payer.

    MHCP quantity limits and thresholds apply to all recipients unless the provider is requesting payment only for Medicare co-insurance or deductible.

    Eligible Recipients

    PAP devices and related supplies are covered for eligible recipients with a diagnosis of obstructive sleep apnea made by a physician with experience diagnosing and treating sleep apnea, using a sleep study or other appropriate diagnostic tool.

    Covered Services

    Codes: E0470, E0601, A4604, A7027-A7039, A7044-A7046
    The provider may dispense a CPAP device for the first three months’ rental based on a physician’s order that includes a diagnosis of obstructive sleep apnea. During the 6th to 12th week of treatment, the supplier must verify that the recipient is complying with the ordered therapy. If the recipient has not achieved compliance by the 12th week, but has made consistent progress toward compliance, MHCP will continue to cover the CPAP device for an additional eight weeks. If the recipient has not achieved compliance after the additional eight weeks, the rental should end and the provider should take the equipment back.

    MHCP will pay for rental of a Bi-PAP device without backup rate, with authorization for recipients with obstructive sleep apnea, when there has been a failed trial of CPAP or if there is a medical contraindication to CPAP. During the 6th to 12th week of treatment, the supplier must verify that the recipient is complying with the ordered therapy. If the recipient has not achieved compliance by the 12th week, but has made consistent progress toward compliance, MHCP will continue to cover the Bi-PAP device for an additional eight weeks. If the recipient has not achieved compliance after the additional eight weeks, the rental should end and the provider should take the equipment back.

    MHCP will pay for the purchase of a CPAP or Bi-PAP device with authorization if the recipient has a third party insurance that requires purchase rather than rental.

    For recipients requiring a Bi-PAP device with backup rate, or for recipients requiring CPAP or Bi-PAP who do not have obstructive sleep apnea, refer to the Respiratory Equipment policy.

    Recipient Compliance

    To accomplish an accurate and valid verification of compliance, it must be clear that the recipient is using the equipment.

    MHCP does not specify the method to use to verify compliance.

    Keep documentation of the compliance verification in the recipients file. Recommended documentation includes the following:

  • • Date of verification
  • • Method of verification
  • • Name of the treating provider
  • • Name of the person within your organization that performed the verification
  • If the recipient is not using the equipment, the rental should end and the provider should take the equipment back.

    Before dispensing masks or other supplies, providers must verify with the recipient that the CPAP or BiPAP device is still in use, and that replacement of the supply is necessary because the existing supply is damaged or otherwise worn out.

    Refer to the Medical Supply Coverage Guide (PDF) for coverage information and limits on supplies not specified here.

    Included with initial dispensing:

  • • Compressor
  • • CPAP valve (if separate from mask)
  • • Disconnection alarm (if needed)
  • • Filters
  • • Fuses
  • • Instruction manual
  • • Manometer
  • Separately billable at initial dispensing:

  • • Head gear
  • • Mask
  • • Tubing
  • • Humidification device
  • Noncovered Services

    The following are not covered:

  • • Carrying case is a noncovered convenience item and is not medically necessary.
  • • A positive airway pressure device is not covered after the third month unless the supplier has verified patient compliance as described above.
  • Authorization

    Follow these authorization guidelines:

  • Authorization is required for all purchases of positive airway pressure devices. Documentation must show that the primary payer requires purchase rather than rental of the device.
  • • Authorization is required for maintenance service agreements for E0470. Maintenance service agreements are not available for E0601.
  • • Authorization may be approved for PAP supplies in excess of MHCP limits when necessary. The medical review agent will not approve authorization of supplies needed due to willful or careless destruction by a recipient unless documentation shows that the destruction was because of the physical or mental impairment of the recipient.
  • Submit authorization requests and required documentation to the authorization medical review agent.

    Billing

    Refer to the following when billing for positive airway pressure devices:

  • • Positive Airway Pressure devices are capped rental only unless a primary payer requires purchase.
  • • Use X12 Batch or MN–ITS 837P Professional electronic claim.
  • • Report the ordering provider in the Other Provider Types section of the MN–ITS Interactive claim.
  • • If the recipient has Medicare, MHCP will pay the deductible or co-insurance on any units for which Medicare made payment. Any units for which Medicare denies payment must meet MHCP quantity and coverage limits.
  • • Bill the first three months using modifier RR and modifiers KH, KI or KJ as appropriate.
  • • When billing for rental after the first three months, use modifiers RR, modifiers KH, KI or KJ as appropriate and modifier KX if documentation in the file supports that the supplier has verified recipient compliance with treatment. Do not use modifier KX if the supplier has not verified compliance, or if the supplier has information that the recipient is not compliant with treatment except as described above.
  • • MHCP will deny claims for rental past the first three months, unless the RR and KX modifiers are present to indicate recipient compliance with treatment.
  • • Shipping and delivery costs are included in the MHCP maximum allowable payment. Do not bill either MHCP or the recipient separately for these costs.
  • • PAP devices are expected to serve the recipient for at least five years. If a device is stolen or damaged beyond repair, a replacement device may be covered. Submit a claim with a Claim Attachment Criteria explaining why a replacement is required.
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