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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