CPAP billing question

[bmaguire]

I have the same problem. I understand that companies will bill insurance the anything they can get away with. The code A7030 doesn't really specify what a "full face mask" is. I don't see where it describes if it includes a cushion or not. The supply companies are double dipping, and here is why....

Here is ResMed's "reimbursement fast facts". They have a table for "Initial Setup" and "Ongoing Replacement Supplies"
https://document.resmed.com/documents/a ... sories.pdf

For initial setup they show a complete mask system as A7030 + A7035, which is the codes for "Full Face Mask" and "Headgear"
For Ongoing Replacement Supplies they list "Frame with cushion/pillow" as A7030, which is the code for "Full Face Mask".

Clearly A7030 - Full Face Mask includes the cushion.

Later in this document the list the following Q&A. Notice that they list a combination of two codes (A7030,A7034,A7027) are codes for the frame with cushion/pillow and A7035 is for the headgear.

Q: Does the mask system (A7030, A7034, A7027) and headgear (A7035) include the cushion/pillows or should they be billed separately?
A: The mask and headgear are expected to be “complete” accessories, which include the cushion or pillows.

What the supply companies are doing, they see that there is a code A7031 for a replacement cushion and thought, hey, the CPAP company is including a cushion with the frame so we can bill for the cushion and frame separately and get paid more. We'll just call A7030 the frame part of it and then bill separately for the cushion. The description for A7030 is generic enough that it doesn't really specify what "Full Face Mask" means. Resmed's document is very clear about it. They even have a Q&A that addresses this.

[ChicagoGranny]

The suppliers are following Medicare guidelines for billing parts and masks. They have to bill different items under different codes because the replacement schedules differ.

For instance, the Medicare replacement schedule for FFMs is one per three months; for the cushion, it is one per one month; and for the headgear, it is one per six months.

https://oig.hhs.gov/oei/reports/oei-07-12-00250.pdf