CPAP billing question

[chunkyfrog]

If insurance is not pitching in, there in no reason to limit yourself to places you can walk into.

[palerider]

If insurance is not pitching in, there in no reason to limit yourself to places you can walk into.

and lot$ of rea$on$ not to.

[doc4bax]

This DME company is telling me that A7030 is the code for the frame only. She says "full" means full frame. The full does not mean full as in including the headgear, the frame and the face pillow. Any thoughts? Sounds like a scam to me.

[ChicagoGranny]

This DME company is telling me that A7030 is the code for the frame only. She says "full" means full frame. The full does not mean full as in including the headgear, the frame and the face pillow. Any thoughts? Sounds like a scam to me.

She probably doesn't know what the hell she is doing. The codes are listed below. Clearly, A7030 is a complete mask, not just a damn frame.

Is this DME in your insurance company's network? If so, I would call the insurance company and ask them to straighten our their provider's idiocy. You may need to speak to a supervisor at your insurance company.

CPAP/BiPAP MASK INSURANCE (HCPCS) CODES

A7030 Full Face Mask used with Positive Airway Pressure (CPAP/BiPAP/APAP) Device

A7034 Nasal interface (mask or cannula type) used with positive airway pressure (CPAP/BiPAP/APAP) device , with or without headstrap

A7044 Oral interface used with positive airway pressure (CPAP/BiPAP/APAP) device

A7027 Combination oral/nasal mask, used with continuous positive airway pressure device

[ChicagoGranny]

BTW, A7031 is for a replacement cushion, not the cushion that is included with a new mask.

[Janknitz]

My understanding is that it's standard practice for DME's to part out the mask, and bill the cushion, headgear, and mask frame separately even when you are actually receiving a complete packaged mask. Somehow, this is not considered Medicare fraud, even though Medicare pays more for the parts than the complete mask.

Then, as icing on the cake, since packaged whole masks are often fit packs with multiple sizes of cushions, the DME will often steal your other sizes of cushions from the fit pack (yes, I DO consider this stealing) and sell them separately to others.

[LoftisX4]

Some of this is going to be old hat for this forum, but it seems that some users aren't aware:

Every piece of your equipment that requires normal re-supply has its own code. There are no codes for "packages," or "bundles," so even though the manufacturer puts multiple components in one factory-sealed package, your insurer needs to monitor how often you replace each part of the machine, including the machine itself. The supplier is legally required to report each code/component.

The insurance processes the order according to the normal re-supply delivery schedule that meets their guidelines:

Typical Replacement Schedule
Mask - 1 every 90 days
Mask Cushion - 1 every 30 days
Nasal Pillows - Pair every 30 days
Tubing - 1 every 90 days
Headgear - 1 every 180 days
Non-diposable filters - 2 every 180 days
Disposable filters - 2 every 30 days
Machines - 3 - 5 years

Further, the first mask interface delivered includes a small, medium and large set of pillows, while the supplier is working to determine which size is appropriate for the patient. This is included in the initial setup only. After the correct size is determined, the patient only has coverage for pillows that fit appropriately, and "extras" that are not documented to be the correct size for the patient are non-covered.

Resources:
https://www.directhomemedical.com/direc ... -page.html
https://www.horizonblue.com/providers/p ... p-supplies

[chunkyfrog]

The DME's do not go to prison for parting out the masks, like
patients are not prosecuted for possessing software,
and provider manuals, or to adjust our own machines.
Balanced, if not fair. I take what I can get, and let the vermin live.

[Janknitz]

Further, the first mask interface delivered includes a small, medium and large set of pillows, while the supplier is working to determine which size is appropriate for the patient. This is included in the initial setup only. After the correct size is determined, the patient only has coverage for pillows that fit appropriately, and "extras" that are not documented to be the correct size for the patient are non-covered.

I call baloney on this. If the DME paid extra for the supplied fitting cushions, that would make sense, but they don't. Manufacturers sell the individual parts or they sell the full mask in a fit package--the full mask in a fit package costs less than the individual items parted out. So when a DME takes the extra cushions out of the fit package and sells them individually, they are taking things they did not pay for and selling them for profit.

You can see this for yourself (understanding that these are retail prices) Go to https://www.cpap.com/productpage/resmed ... dgear.html. You can buy an entire Airfit P-10 mask for $99 including three sizes of nasal pillows. If you buy individual parts instead, (click on the "replacement parts" tab), you will see that the mask assembly kit is $74, the headgear is $25, a single nasal pillow is $19, and a pair of headgear clips is $5 for a grand total of $123. That's how the DME will bill for the entire Airfit P-10 mask, even though they get it from the manufacturer in the fit pack as one item. So they will be reimbursed for the mask parted out and then take out the extra nasal pillows and sell those for profit, when their cost is less, not more, for the fit pack. Sweet deal for the DME.

[chunkyfrog]

Insurance vs self-pay is complex, and needs to be carefully evaluated for each instance.
Find out what your out-of-pocket would be for each scenario, and act accordingly.

[doc4bax]

I got billed A7030 (full face mask) which includes the frame, cushion and the headgear that's why its says FULL. On top of this I got billed A7031 (replacement cushion) which I did not receive. DME CO says it's billed separate. How can you bill for the cushion separate when you also bill for a full face mask which includes the cushion?

[LSAT]

I got billed A7030 (full face mask) which includes the frame, cushion and the headgear that's why its says FULL. On top of this I got billed A7031 (replacement cushion) which I did not receive. DME CO says it's billed separate. How can you bill for the cushion separate when you also bill for a full face mask which includes the cushion?

Wait for your Explanation of Benefits

[ChicagoGranny]

I got billed A7030 (full face mask) which includes the frame, cushion and the headgear that's why its says FULL.

It says "full" because it is the type of mask that covers your nose and mouth. Other types include "nasal" (nose only) and "oral" (mouth only).

Like LSAT said, if you are using insurance, you should wait for your EOB.

[chunkyfrog]

Since each component has its own code, insurance/Medicare pays for each separare part.
Local dealers usually charge separately--even though the parts may be packaged together--
and may even be non-separable. (Like recent Resmed humidifiers), expect them to be billed individually. In the insurance world, EVERYTHING is charged for. There is no free cushion included with a mask---even our sponsor's prices allow for the cushion/pillow when a kit is sold.

[doc4bax]

I attached the EOB. The first charge is the A7030 and the second is the A7031. OK so the A7030 is a full face mask meaning it covers mouth and nose. Then why am I being billed for a second one (A7031) "replacement full face mask" since A7030 includes it? Thanks!