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New Unprocessable Claim Rejections for Continuous Positive Airway Pressure Device (E0601)

National Government Services, the Jurisdiction B DME MAC has identified an increase in the number of requests for reopenings for CPAP device (E0601) claims. While the reopening process is available to correct minor errors and omissions it is more cost effective to submit the claim correctly the first time.

Effective April 1, 2014, National Government Services will begin rejecting claims for CPAP equipment and accessories with ANSI code CO-4, “procedure code is inconsistent with the modifier used, or a required modifier is missing.” when the ICD-9 code indicated on the claim is something other than ICD-9 code 327.23-Obstructive sleep apnea (adult) (pediatric) and the KX modifier is present.

KX - Requirements specified in the medical policy have been met

The LCD for PAP devices advises that CPAP devices are covered if the patient has a diagnosis of obstructive sleep apnea (327.23) documented by a sleep test that meets the Medicare coverage criteria. On initial coverage for the first through third months of rental of the E0601, if the beneficiary meets all of the coverage criteria indicated in the Indications and Limitations of Coverage and/or Medical Necessity section of the LCD, suppliers are instructed to add a KX modifier to codes for CPAP equipment and accessories. For continued coverage, claims submitted for the fourth month and any months thereafter, the supplier must also add a KX modifier to codes for CPAP equipment and accessories only if both the "Initial Coverage" criteria and the "Continued Coverage" criteria in the “Indications and Limitations of Coverage and/or Medical Necessity” section of this policy have been met.

Submission of the KX modifier is not only an indication that the supplier either has documentation on file or access to the documentation required to meet medical necessity, it is also an indication that the policy restricted diagnosis has been met. All DMEPOS suppliers are required to code their claims with the appropriate ICD-9 diagnosis code as indicated in the medical record.

The PAP device LCD require the presence of a KX, GA, GZ, or GY modifier to indicate whether the coverage criteria outlined within that policy are or are not met and whether an ABN has or has not been properly executed. Suppliers are reminded of their right to execute an ABN if the beneficiary does not meet all of the coverage criteria indicated in this policy. Claims rejected with ANSI code CO-4 are not eligible for an appeal or reopening and must be resubmitted with the appropriate diagnosis and modifier combination.

For detailed claims submission and billing instructions, suppliers are encouraged to review the LCD and policy article for PAP devices for the treatment of obstructive sleep apnea.

New Unprocessable Claim Rejections for Continuous Positive Airway Pressure Device (E0601)
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