Standard Billing Codes?

I seem to recall seeing a form in one of the posts here but I cant find it.

Are there industry standard billing codes for the various types of machines that are used when billing to the Insurance company, or do the Insurance companies have their own codes?

Krelvin wrote:Are there industry standard billing codes for the various types of machines that are used when billing to the Insurance company...

Yes:

http://www.healthcare.philips.com/pwc_h ... _Hints.pdf

Perhaps this is what you are looking for?

CPAP Billing Codes

or

More Billing Codes

Sludge wrote: Yes:

http://www.healthcare.philips.com/pwc_h ... _Hints.pdf

Sludge's link also has quantity/frequency guidelines--on the lower half of page six (green highlighted).

Exactly what I was looking for... thanks.

Planning for my upcoming visit with the Sleep Dr to go over my sleep study and get a new RX for a new machine etc...

I am making a checklist for both when I see him and when I start dealing with the DME again so I don't forget anything or let them slip something past me. So far the Sleep Dr has been upfront but I know the DME well and have dealt with their crap before.

One of the games that DME's play sometimes is saying they don't have an RX for hoses and tubing and when you place an order they will then try to bill you directly for them. Making sure the RX's include the codes for those means that is not an excuse. Doesn't mean they won't try, but eliminates it as a valid excuse.

Knowing up front what the Insurance company allows for replacement parts, masks etc... also means I can create a schedule to get them even if I don't actually need them right then when they are covered.

My prescription specifically says auto CPAP with a pressure of 4-20. The prescription is 3 years old. My DME has never ask me for an updated prescription or a specific prescription for mask, hose, etc. I think your DME is playing games with you. If you are unhappy with the DME...find a different one. The code is used by the DME for billing purposes to the insurance company. The Doctor on the prescription doesn't use the code.

Aside from getting a back up for each item, why would you want to order items you don't need... ? Most items last a loong time.

I have insurance that covers 100% of the costs or at least until the end of the year when co-pays start coming into effect. I already paid out of pocket max for the year. Otherwise they cover 80-90%.

The comments related to how a DME may play games is what I've read specifically with the DME I am forced to use for the Insurance coverage. This has already been a very expensive summer, going out of network to get this expensive and unnecessary if I don't have to.

Having a spare mask is useful when the one you are using breaks. Same thing with hoses. I don't sleep without my machine ever. so not being able to because of a failure in part of the equipment is a big issue. I have had masks break before several times. I typically replace my masks every 7-8 months but the insurance covers every 6 months.

How Often UHC Insurance replaces items.

Took a while, but I finally got UHC to provide info on what their replacement policies were for the various codes.

The problem seems to be that this is not actually published info. While you may also have UHC coverage, the plan you have may be quite different from what I have. Even if you have the same "plan" you may not have the same coverage as the company that I work for can apparently taylor or adjust what is and isn't covered and for which time periods.

So I'm not sure how useful this is. I did find it interesting that none of the supply codes have any replacement timeline, just as needed. I'm sure the DME will not provide the same info but I haven't had to deal with them yet. Won't be until after the 10th of this month.

Below is the message I got back from UHC when I asked how often various items could be replaced "under my plan". It also clarified a previous message they had sent me where the deductable was listed as something completely different from what my plan says (which is up to $850 which I have already spent). The previous message said $550 which didn't match anything I had in writing.

Network Coverage
Your coverage when you use a network doctor, hospital or facility is - 80% of eligible expenses after satisfying $850 deductible.

Non-Network Coverage
Your coverage when you use a non-network doctor, hospital or facility is – 60% of eligible expenses after satisfying $1,700 deductible.

A CPAP is considered durable medical equipment and can be replaced every 3 calendar years. The supplies for the CPAP do not have a restriction for time limits. For example, a mask for a CPAP can be replaces as often as needed.

I am listing each CPT/HCPCS code that you had listed and the replacement timeline for each code below.

E0470 – 3 calendar years
A7030 – as needed
A7037 – as needed
A4604 – as needed
A7038 – as needed
A7039 – as needed
A7046 – as needed

Get everything in writing, and nag, nag, nag.
3 years on a machine sounds liberal, but I'd read the fine print--carefully . . .
The rest sounds like a rough attempt to emulate Medicare's new "non-schedules".
--Don't let those rascals get away with anything.
(resisting urge to slam UHC mercilessly)

I had a problem earlier on with my dme. They stated that the resmed Elite S9 was not covered. Well thank god Pugsy or someone else on this forum stated to me the Billing Codes. the resmed elite s9 code was e0901. So I stated this and they had no problem after that. I found them in a lie and they knew it. Show instead of the dme fighting with me, I believe they just switched it out, so they would not be bother by me. Plus I called them like 7 times the same day. So don't let them state an bricked device has a differnt billing code. It does not it has the same billing code as the type of cpap machine used. Don't let them lie to you.