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Diagnosis Requirements for Positive Airway Pressure Devices – Revised

(This article was updated on October 9, 2013 to clarify the statement in the second paragraph by adding the bold text.)

National Government Services has identified an increase in requests for reopenings from suppliers changing the diagnosis code submitted on their original claim. In order for a beneficiary to meet coverage criteria for a PAP device, the documentation in the physician’s progress notes must support the diagnosis and physician’s order.

A single level PAP device (E0601) is covered if the patient has a diagnosis of OSA documented by a sleep test that meets Medicare coverage criteria.

The local coverage determination (LCD) for positive airway pressure devices requires the patient to present with the diagnosis of OSA. In the past, due to a lack of a specific ICD-9 code for OSA, suppliers were instructed to submit qualifying claims under a generic ICD-9 for general sleep apnea. In 2005, the ICD-9 code 327.23 was established for obstructive sleep apnea. The LCD for PAP devices is very specific regarding the diagnosis that is required in order to meet coverage criteria. Therefore, the ICD-9 code 327.23 must be used for PAP device claims instead of the general sleep apnea code when the patient meets this requirement.

Diagnosis Requirements for Positive Airway Pressure Devices – Revised
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