RT Hoseheads face problems too

[Vasily]

How do you explain than when Insurance gets the script and it says APAP?

[Guest]

How do you explain than when Insurance gets the script and it says APAP?

Why does the script have to say APAP? Since the billing code is the same, can't you just order an Auto and set it up at single pressure (as mentioned by Snoredog) as a CPAP and then later change it to whatever you want?

With ordering from CPAP.COM, you can order an APAP on a CPAP Rx, but you can't order a CPAP on an APAP Rx.

I never got the opportunity to test it out with my insurance carrier because I mainly cared about getting a machine with recording capabilities.....and I wanted to see how this therapy was going to work before getting an Auto. I subsequently purchased my two Autos out-of-pocket.

There's gotta be a way of circumventing this insurance mess somehow.

Den

[Babette]

Vasily - getting an APAP usually requires a letter of medical necessity from the doctor. Get the doctor to write it for YOU and for your patients needing APAP's. Just work that into your standard procedure.

Good luck!!!!

So sorry to hear you're getting scr*wed too...

Hugs,
Babs

[Guest]

I have been using CPAP for about 3 1/2 years, but have been feeling a little sluggish lately.

WHY? Don't you have a Pro 2? (or is it the older Pro?) If you have the Pro 2, you should be able to see from the downloads what might be causing your problem(s).

Oh, heck......just get the one you want from CPAP.COM. Do I also have to remind you that it's YOUR therapy?

Den

[rested gal]

I'm still not understanding why the DME (if they want to...and less profit might make them not want to) cannot simply bill the insurance company for a CPAP machine with the usual HCPCS code E0601 for "CPAP", yet give you the "cpap" you want....an auto-titrating cpap machine.

Because that's what an autopap is. It's just a "CPAP" machine blowing one straight pressure at you. It has a feature called "auto-titration" that can be turned on to vary that single straight pressure as your breathing changes, but it's still ONE single amount of continuous positive air pressure at a time.

Not like bi-level devices which have their own different HCPCS code because they deliver two separately SET pressures (higher for inhaling, lower for exhaling) for each respiratory cycle (breathe in/breathe out.)

But I still don't understand why it makes one iota of difference to the insurance company whether the Rx says "cpap" or says "apap", if the billing code being submitted says E0601.

Is the billing department trying to use HCPCS E1399 (billing code for things that don't have their own specific code) when they see an "apap" Rx???? If that's what they're doing, perhaps it would go through fine if they simply use the normal cpap code E0601. Because this can't be said enough -- an autopap IS a cpap. It's a cpap with the capability to auto-adjust the single pressure it delivers, but a "cpap" nonetheless.

If...big "if", 'cause I don't know... if the owner or manager of the DME you work for has instructed the billing department to handle "apap" Rx's in certain ways (like "Use the E1399 code, not the cpap E0601 code") in hopes the insurance company will deny the claim, perhaps that's the stumbling block.

Might be the way the company you work for intends to avoid whenever possible (understandably, I might add) giving out the more expensive auto-titrating CPAP machines -- but blaming it on the insurance company's denial. I'm not saying that your friend in the billing department is at fault. She's just handling it the way she's been trained to do it....if they are using E1399 for autopap Rx's.

Can you ask your friend in billing... are the apap Rx's being submitted with the E0601 code? Or are they being submitted under the E1399 code?

Vasily, do you think this Rx would get you an autopap? since the M series Auto with A-Flex is the only machine that has A-flex:

CPAP with A-Flex
cpap pressure 10 cm H20

Billed, of course, as what it is...a cpap machine under E0601.

Of interest, near the bottom of this page:
http://www.puritanbennett.com/remb/sleep.aspx#coding

"Coding for Auto-Titrating CPAP Units
Coverage and coding for autotitrating CPAP units is currently the same as coding and coverage for conventional CPAP, using HCPCS code E0601."

An interesting previous thread about cpap/autopap billing codes are here:
viewtopic.php?t=15582
where mattman, who worked for a DME, mentioned the "catch all" code E1399 as another way to bill for an APAP instead of billing it as a cpap.

And this thread where mattman didn't seem to quite understand some of neversleeps' questions on page 2, about the "catch all" code E1399.
viewtopic.php?t=16463

[gasp]

[quote="Vasily"]So as most of you know I am an RT and RPSGT. I have been using CPAP for about 3 1/2 years, but have been feeling a little sluggish lately. So rather than playing "Pin the tale on the donkey" with my pressure, I decided that I would go to the Sleep Doc I work for and get a script for an APAP. Got the script and asked the girls in billing (I now work as an RT in a DME) to get the pre-auth for my machine. Imagine my surprise when I came back to my office later that day and found a voice mail message from the Insurance company denying my claim for an APAP, but authorizing me for a CPAP. I thought surely they were mistaken, so I called the billing girls and they called them back. Nope, no mistaking, the Insurance would not authorize an AUTOCPAP, but were authorizing a regular CPAP.
So my manager said, no problem, you can use your employee discount (which is "cost + $1") and just buy it outright. Great idea, except cost +$1 is $85 more than it would cost me to buy it from CPAP.com!! We are talking about an "M Series" Auto with AFLEX here, core package which includes humidifier.

This all happened about 2 months ago, since that time I started tracking which patients came in with an APAP script and actually got it paid by insurance. Results, in the last 1 1/2 months I have given out 7 APAP's, 5 of which were denied by their insurance. 2 of those 5 people, actually came in and told me that they had called their insurance and asked if it was covered and had been told that it was. 4 out of the 5 had the same insurance, so I called the insurance company and asked, why they were denied. The rep told me that they were denied because there wasn't any supporting evidence that the patients were not compliant with CPAP use. Infact just the opposite, they were very compliant which made the APAP not medically necessary, because it was only wanted for comfort and they don't pay for comfort items. One of the patients even had a clause in his policy that required him to be noncompliant for 60 days or longer.

So now our manager has adopted a policy that all APAP's require a preauth from insurance prior to the patient taking possession of the equipment. Needless to say my job just got a little more frustrating today.

[j.a.taylor]

Vasily,

Wow! What a string of replies to your post!

I think it just goes to show that we must all continue to be advocates for the cause. When we educate ourselves and advocate for ourselves things change for the better, but it is often a long process.

It's great to know that there's somebody on the inside, who understands and can advocate for others.

And it reminds us all that sleep docs, DME's, RT's and others (even some insurance companies) aren't all villains.

We just need to keep being squeaky wheels. After all, as the saying goes, "the squeaky wheel gets the oil."

[Guest]

I just got back from dinner with my frined from our billing dept and her husband. She said we only bill the E0601 code for CPAP's of any kind to include APAP's. She went on to say that about 6-8 months ago many of the Insurance companies WE have contracts with, started requiring preauth's for CPAP's and CPAP supplies. When they call to get the preauth's the Insurance rep asks what the RX says specifically, even down to if it says they get headgear or not.

Ofcourse like many of you have stated, we could give them an APAP setup in CPAP mode even if the order says CPAP. However our Corporate policy (which I don't agree with at all, for the record), states that we give EXACTLY what the script from the doctor states. Sure I could go against it and give out an APAP on a CPAP order, I may get away with it once. But i'm sure the next time it may cost me my job.

Now I also asked my manager today, what happens if we give out an APAP to a patient and their Insurance denies the claim? She said, (And after checking the patients records, she is correct) the equipment is a complete writeoff for us. The only time we would see any money is if they had a copay or hadn't met their deductible yet. I didn't check to see if that applied to any of the 5 that had been denied. If not it's about a $700-$800 write off for the DME, well atleast my DME.

One last note, casue I'm sure someone will bring it up, we only bill the allowable billable rate for Medicare. I only mention this because I know some DME's bill above this rate and the patient is responsible for whatever the insurance doesn't pay. The only money we ever get from a patient that bills to their insurance is money the the Insurance company makes them pay, ie co-pay and deductible.

RG,

If I got a script that said
CPAP with A-flex
CPAP pressure 10 cmh2o

I would have to call the Doc who wrote it and have him verify if he meant APAP or CPAP. This is due to our Corporate policy, the policy states that it MUST state APAP AND MUST give a pressure range for it to be a valid APAP order. I've already expressed my feelings on that policy earlier so I don't think I need to repeat it.


Den,

No, you don't need to remind me. That's why I called my Resmed rep first thing this morning and he's sending me an S8 Auto to "demo" until he comes up for a visit in Sept.

Snoredog,

I still stand by my claim that there is only 1 HCPCS code for an APAP.

[Snoredog]

Snoredog,

I still stand by my claim that there is only 1 HCPCS code for an APAP.

Well you go on believing what you want to believe, your response doesn't surprise me any, we see RT's like you giving bad advice here every day so it is no surprise you don't understand the process of obtaining a machine either.

Hey good luck with that plain jane CPAP , hopefully your insurance won't make you keep it for the next 5 years. Maybe someone else can explain how you got screwed by your own corporate policy LOL

[GARYHRX]

THe government folks that set up HCPCS codes are not noted for having multiple codes for similar items and updates take along time to happen. I know from pharmacy billing for Medicare drug coverage for transplant patients that you, the provider, must make your billing fit into thier code. For example drug A has a code of #1234 for a 1 mg. tablet. THere is a 5 mg tablet available but no code is available so the provider must bill the 1 mg code 5 times. The only folks that bill at the medicare allowable are those that are billing to Medicare or Medicaid. That is because if you don't bill that way your claims are rejected.

When providers bill pvt insurance, the claim amount submitted is many times far in excess of what an item could be purchased for in a retail store or on-line. The culprit in this scenario is the insurance company. They will not tell the provider what they will re-imburse for a particular item because they make different deals with each provider. What most people don't understand is that providers are NEVER paid the amount that they bill. But if they under bill (ie use medicare allowable) the insurance company will pay exactly what you bill them for even if their maximum reimbursement is alot higher.

Beginning to get the picture?

One never has to deal with these issues if they are independently weathy and can purchase all their equipment for cash. But most of us are not that fortunate. So educate yourself. Always question.

[Wulfman...]

FWIW

Billing Codes:

https://www.cpap.com/cpap-faq/Insurance.html#198

What are the CPAP, BiPAP and Sleep Apnea related billing codes?

* EO601 RR is CPAP rental.
* E0601 NU is CPAP purchase.
* A7034 is CPAP nasal mask, including all nasal masks, Nasal Aire, Breeze, Spiritus.
* A7032 is CPAP nasal mask cushion.
* A7030 is CPAP Full Face mask.
* A7031 is CPAP Full Face mask cushion.
* A7044 is CPAP Full Oral Interface.
* A7046 is CPAP Humidifier Chamber.
* A7037 is CPAP tubing, long and short hoses.
* A7038 is CPAP disposable filter.
* A7039 is CPAP gross particle (foam) filter.
* A7035 is CPAP headgear.
* A7033 is CPAP nasal pillows.
* A7036 is CPAP chinstrap.
* E0561 NU is CPAP Passover Humidifier
* E0562 NU is CPAP Heated Humidifier
* E0470 RR is BiPAP rental.
* E0470 NU is BiPAP purchase.
* E0471 RR is BiPAP-ST rental.
* E0471 NU is BiPAP-ST purchase.


Other CPAP items are listed under E1399, which is miscellaneous.

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You can also check this site link (this page is "E" codes):

http://www.noridianmedicare.com/dme/new ... r16_e.html

There is no code for APAP.....just CPAP and Bi-Level.

Den

[Wulfman...]

Maybe I should have said there is no SEPARATE code for "APAP".....as it falls under the CPAP category.

Den

[Guest]

Snoredog,

I would like to know where you are getting the info about different codes for APAP's.

Well you go on believing what you want to believe, your response doesn't surprise me any, we see RT's like you giving bad advice here every day so it is no surprise you don't understand the process of obtaining a machine either.

Snoredog,

I appreciate all your contributions to this forum, but I think, in this case, you're being unfair to Vasily. After you stated that there was a unique billing code for an APAP, he simply asked you for the code. Instead of answering his good faith question, you responded with a personal attack.

[Bamalady~]

Infact just the opposite, they were very compliant which made the APAP not medically necessary, because it was only wanted for comfort and they don't pay for comfort items.

My Insurance has this same wording about comfort.....I think it is just nuts. One would think that anyone needing DME stuff would also need to be comfortable!

The entire thing...Insurance, Docs, Suppliers...makes me crazy! And yes, I will agree there are some good ones out there, but geeze, XPAPers are sleep deprived, especially in the beginning, and have a hard time dealing with all this stuff.

[Guest]

Snoredog,

I would like to know where you are getting the info about different codes for APAP's.

Well you go on believing what you want to believe, your response doesn't surprise me any, we see RT's like you giving bad advice here every day so it is no surprise you don't understand the process of obtaining a machine either.

Snoredog,

I appreciate all your contributions to this forum, but I think, in this case, you're being unfair to Vasily. After you stated that there was a unique billing code for an APAP, he simply asked you for the code. Instead of answering his good faith question, you responded with a personal attack.

if you are going to ask a question then argue every answer you get back in return then the hell with you, you deserve to get screwed like he did.

do I even care what you think? not at all, could care less.