A7025 HIGH FREQUENCY CHEST WALL OSCILLATION SYSTEM VEST, REPLACEMENT FOR USE WITH PATIENT OWNED EQUIPMENT, EACH
A7026 HIGH FREQUENCY CHEST WALL OSCILLATION SYSTEM HOSE, REPLACEMENT FOR USE WITH PATIENT OWNED EQUIPMENT, EACH
Coverage Indications, Limitations, and/or Medical Necessity
For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.
Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee For Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.
While this Standard Documentation language makes reference to " Affordable Care Act Section 6407 (ACA 6407) requirements", technically these requirements are found in the Social Security Act Section 1843(a)(11)(B) and its implementing regulation at 42 CFR 410.38. The CMS regulation contains the details for the face-to-face examination, written order prior to delivery and the list of items subject to these requirements.
For an item to be covered by Medicare a detailed written order (DWO) must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed DWO, the item will be denied as not reasonable and necessary.
For some items in this policy to be covered by Medicare, a written order is required to be in the supplier’s file prior to delivery of the specified item(s). There are two differing order requirements that may apply depending upon the specific item prescribed:
The Affordable Care Act Section 6407 (ACA 6407) specifies the five elements that must be contained in this written order. For purposes of this policy, this order is termed the 5-element order (5EO).
A written order prior to delivery (WOPD) that meets all of the requirements of a standard detailed written order (DWO).
If the supplier delivers an item addressed in this policy without first receiving the completed order, the item will be denied. Refer to the DOCUMENTATION REQUIREMENTS section of this LCD and/or to the NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section of the related Policy Article for information about these prescription requirements and the type of denial that will result from non-compliance.
High frequency chest wall oscillation devices (HFCWO) (E0483) are covered for beneficiaries who meet:
Criterion 1, 2, or 3, and
Criterion 4
There is a diagnosis of cystic fibrosis (see diagnosis codes that support medical necessity section below).
There is a diagnosis of bronchiectasis (see diagnosis codes that support medical necessity section below) which has been confirmed by a high resolution, spiral, or standard CT scan and which is characterized by:
Daily productive cough for at least 6 continuous months; or
Frequent (i.e., more than 2/year) exacerbations requiring antibiotic therapy.
Chronic bronchitis and chronic obstructive pulmonary disease (COPD) in the absence of a confirmed diagnosis of bronchiectasis do not meet this criterion.
The beneficiary has one of the following neuromuscular disease diagnoses (see diagnosis codes that support medical necessity section below):
Post-polio Acid maltase deficiency Anterior horn cell diseases Multiple sclerosis Quadriplegia Hereditary muscular dystrophy Myotonic disorders Other myopathies Paralysis of the diaphragm
There must be well-documented failure of standard treatments to adequately mobilize retained secretions.
If all of the criteria are not met, the claim will be denied as not reasonable and necessary.
It is not reasonable and necessary for a beneficiary to use both a HFCWO device and a mechanical in-exsufflation device (E0482).
Replacement supplies, A7025 and A7026, used with beneficiary owned equipment, are covered if the beneficiary meets the criteria listed above for the base device, E0483. If these criteria are not met claims will be denied as not reasonable and necessary.
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
N/A
Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
N/A
CPT/HCPCS Codes
Group 1 Paragraph:
The appearance of a code in this section does not necessarily indicate coverage.
HCPCS MODIFIERS:
EY - No physician or other licensed health care provider order for this item or service
GA - Waiver of liability statement issued as required by payer policy, individual case
GZ - Item or service expected to be denied as not reasonable and necessary
KX – Requirements specified in the medical policy have been met
ICD-10 Codes that Support Medical Necessity
Group 1Codes
ICD-10 CODE DESCRIPTION
A15.0 Tuberculosis of lung
B91 Sequelae of poliomyelitis
D81.810 Biotinidase deficiency
D84.1 Defects in the complement system
E84.0 Cystic fibrosis with pulmonary manifestations
E84.9 Cystic fibrosis, unspecified
G12.0 Infantile spinal muscular atrophy, type I [Werdnig-Hoffman]
G12.1 Other inherited spinal muscular atrophy
G12.20 Motor neuron disease, unspecified
G12.21 Amyotrophic lateral sclerosis
G12.22 Progressive bulbar palsy
G12.29 Other motor neuron disease
G12.8 Other spinal muscular atrophies and related syndromes
G12.9 Spinal muscular atrophy, unspecified
G14 Postpolio syndrome
G35 Multiple sclerosis
G71.0 Muscular dystrophy
G71.11 Myotonic muscular dystrophy
G71.12 Myotonia congenita
G71.13 Myotonic chondrodystrophy
G71.14 Drug induced myotonia
G71.19 Other specified myotonic disorders
G71.2 Congenital myopathies
G71.3 Mitochondrial myopathy, not elsewhere classified
G71.8 Other primary disorders of muscles
G72.0 Drug-induced myopathy
G72.1 Alcoholic myopathy
G72.2 Myopathy due to other toxic agents
G72.89 Other specified myopathies
G73.7 Myopathy in diseases classified elsewhere
G82.50 Quadriplegia, unspecified
G82.51 Quadriplegia, C1-C4 complete
G82.52 Quadriplegia, C1-C4 incomplete
G82.53 Quadriplegia, C5-C7 complete
G82.54 Quadriplegia, C5-C7 incomplete
J47.0 Bronchiectasis with acute lower respiratory infection
J47.1 Bronchiectasis with (acute) exacerbation
J47.9 Bronchiectasis, uncomplicated
J98.6 Disorders of diaphragm
M33.02 Juvenile dermatopolymyositis with myopathy
M33.12 Other dermatopolymyositis with myopathy
M33.22 Polymyositis with myopathy
M33.92 Dermatopolymyositis, unspecified with myopathy
M34.82 Systemic sclerosis with myopathy
M35.03 Sicca syndrome with myopathy
Q33.4 Congenital bronchiectasis
No comments:
Post a Comment