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The Complete Guide to Billing CPAP and HST







Introduction of CPAP and HST


Continuous Positive Airway Pressure (CPAP) devices and Home Sleep Tests (HST) are commonly used treatments for obstructive sleep apnea. Sleep apnea is a potentially serious sleep disorder where an individual's breathing repeatedly stops and starts during sleep. CPAP devices work by delivering constant air pressure to keep the airway open. HSTs are used to diagnose sleep apnea through at-home sleep studies.


Correct billing of these services is critical for receiving proper reimbursement from insurance companies. However, billing can be complex due to changing payer policies, nuances in documentation and specific procedural codes. This comprehensive guide covers everything medical billers need to know for compliant and optimized CPAP and HST billing.


CPAP Billing Guidelines


CPAP or APAP (Auto-Titrating Positive Airway Pressure) devices are the mainstay treatment for obstructive sleep apnea. Here are some key guidelines for billing CPAP services:

Medical Necessity

A sleep test like an HST or polysomnography must be completed to confirm a sleep apnea diagnosis prior to ordering CPAP/APAP. The sleep test must meet medical necessity guidelines established by payers.

CPAP/APAP must also meet the payer's criteria for medical necessity, which is typically based on the apnea hypopnea index (AHI) and/or other documentation about symptoms.


Coding

  • E0601 - CPAP device

  • A4604 - Tubing for CPAP device

  • A7027 & A7028 - CPAP masks

  • A7029 & A7030 - CPAP headgears

  • A7031 - Chin strap for CPAP

  • A7032 - CPAP filters, disposable

  • A7033 - CPAP filters, non-disposable

  • A7034 - CPAP pillows

  • A7035 - CPAP interface, replacement

  • A7036 - CPAP comfort gel pillow

  • A7037 - CPAP insulated tubing


Many payers bundle E0601 with A4604 and A7047 when billed for the initial 3-month rental period. Always check payer policies for bundling rules.


Modifier Usage

  • NU - New DME equipment

  • RR - Rental DME equipment

  • MS - 6-month DME rental period

  • UE - DME purchase


Documentation

  • Diagnosis codes

  • Obstructive sleep apnea (G47.33)

  • Hypersomnia (G47.10)

  • Details about the equipment provided

  • Manufacturer, model

  • Settings (pressure, humidity, ramp, etc)

  • That medical necessity criteria were met

  • Sleep test results

  • Symptoms

  • Prescription

  • Proof of delivery

  • Beneficiary acknowledgement


HST Billing Guidelines


Home sleep tests provide a convenient way to diagnose sleep disorders. They involve wearing portable monitors overnight at home versus in a lab. Here are key guidelines for compliant HST billing:


Codes

  • G0398 - Auto CPAP provided by supplier without a physician order, includes instruction and accessories

  • G0399 - Auto CPAP provided by supplier without a physician order, does not include instruction and accessories

  • G0400 - Auto CPAP provided by supplier with a physician order, includes instruction and accessories

  • 95800 - Sleep study unattended, simultaneous recording heart rate, oxygen saturation, respiratory analysis and sleep time

  • 95806 - Sleep study unattended, simultaneous recording of heart rate, oxygen saturation, respiratory airflow, and sleep time

  • 95810 - Sleep study attended by a technologist

  • 95811 - Polysomnography, sleep staging with 1-3 additional parameters of sleep

Modifiers

  • TC - Technical component

  • 26 - Professional component


Billing 95806 or 95800 alone covers the technical component. Bill with modifier 26 for the interpretation or professional component.


Medical Necessity


Payers may require

  • An evaluation by a physician documenting symptoms indicative of a sleep disorder

  • Patient being an appropriate candidate for a home sleep test rather than formal polysomnography

  • HST being ordered by the treating physician

  • Results interpreted by a physician who manages the patient’s sleep disorder


Documentation

  • Diagnosis codes

  • Sleep apnea (G47.33)

  • Insomnia (G47.00)

  • Order from treating physician

  • Manufacturer, model, and serial number of portable monitor

  • Physician interpretation of results

  • Copy of the sleep test results


Limitations


Most payers limit coverage to a certain number of HSTs per year. For example, Medicare covers up to 2 HSTs per beneficiary per year.


HST vs EEG/Sleep Study Billing


HSTs (95800/95806) describe sleep studies that only record physiologic parameters. If EEG measurements of sleep staging are performed, then codes 95810 or 95811 must be used instead.


Conclusion


Billing for CPAP and HST services requires close attention to coding details, payer policies, and documentation guidelines. BMMS is the trusted partner in navigating the intricate landscape of medical billing, particularly when it comes to CPAP and Home Sleep Test (HST) services. With their specialized expertise, they understand the nuances of these billing processes, ensuring that the clients bill for CPAP therapy and HST accurately and efficiently. Their team of experienced professionals is well-versed in the necessary documentation, coding, and compliance standards required for successful reimbursement. From verifying insurance coverage to handling denials and appeals, BMMS offers comprehensive support, allowing the clients to focus on providing quality patient care while taking care of the billing intricacies.

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