BCBS of AL, HCPCS Insurance Codes

[MagicCityDawg]

I'm new to this world, having my PSG last Saturday after an initial consult on Thursday. While I haven't been back for the interpretation, it was a split-study, so I'm assuming I'm on my way to a CPAP. That being said, I've been doing a lot of reading on this site and others.

I've decided that I would like a fully data capable machine. The idea that there is equipment out there that will help me better understand my response and allow me to adjust as I see fit is great. However, it bothers me to think I may have trouble getting a machine like this due to lower profit margins. To make things worse, the Dr. and DME share an office space. I'm already trying to get "loaded for bear" when that time comes. I hope it won't be a problem, but I am fully prepared to thank the Doc for his time, get my PSG results and prescription and leave. I guess you have to be, right?

Anyway, I found this website (http://www.directhomemedical.com/about/ ... tions.html) that lists HCPCS (Healthcare Common Procedure Coding System) codes for CPAP related equipment. I hope this will help someone. I see the codes mentioned on here, but haven't found a detailed list yet. Hope this helps.

Also, after being on the phone with my insurer, I have the max. allowable costs for BCBS of AL as of 2/8/2011 at 10:15AM CST. I was told these are subject to review and/or change at any time. With that, maybe these will give anyone in Alabama with BCBS (or maybe all of BCBS, I don't know) some numbers, and maybe the rest of you an idea of the max. allowable cost.

For those of you that have been through this before, does this seem about right?

HCPCS.......Modifier..............Max. Allow................Cycle
E0601.......CPAP Device............$806.00.................3 years
E0562.......Heated Humidifier.....$197.00.................3 years
A7034.......Nasal Mask.............$75.99...................6 months
A7030.......Full Mask...............$152.25..................6 months
A7038.......Disposable Filters.....$2.50.....................3 months
A7037.......Tubes...................$12.00...................1 year
A7033.......Nasal Pillows...........$22.00...................6 months
A7032.......Nasal Cushion..........$30.00...................6 months

[Pugsy]

Hmm.
My insurance mimics Medicare.
Filters.. I can have 2 a month
Nasal pillow replacement... I can have 1 a month.
Hose/tubing...I can have 1 every 6 months.
New mask and headgear...1 every 6 months.

I have only used it for mask and headgear, then subsequent nasal pillow replacements as I needed.
Recently got 2 of the fine filters for my machine when I got the new mask.

Machine replacement would be 5 years unless something breaks before then.

[BernieRay]

Those amounts and timeframes seem about right to me. Having BCBS in another state, I used an in-network DME, so I didn't have to worry about max allowable amounts. The in-network DMEs are contracted at set rates. I did, however, pre-screen my local DMEs to be sure to use one that would get me the machine I wanted as opposed to what they wanted to sell.

I had my doc write the Rx for the specific setup that I wanted -ResMed S9 Autoset with Climate Control and Mirage SoftGel mask, no substitutions allowed. That pretty much meant that I had fully bargaining power. Either the DME would provide the equipment on the Rx, or I'd go somewhere else. I didn't have any troubles because of that.

[avi123]

Hi, in my case I have problems with these coverages. I am on Medicare plus a supplementary by BCBS of NC plan "F". I have got a CPAP on 13 months rental and been on it for 4 mo. About replacement parts I get a diff story depending which DME's employee ("clinician") I talk to.


My recent experience:


Till last week I new it that Medicare allows a mask (but apparently it is for a nasal mask and not a FF mask as A7030, which I did not know) replacement at one per 3 months, and face mask interface cushion (but not A7031) replacement at one per month.

Last week, I was told by another clinicians there that their policy changed to one mask per 6 months and no interface offered separately because they get ("buy") full mask only assembled. She added that if I want the interface only I should buy it on the Internet PRIVATLY. Notice that I am talking about the cushion assembly for the Mirage Quattro FF mask system A7031 costing $54, "privately".

After I asked that clinician why the same Cushion is offered separately on the Internet by the SAME DME who also owns an ONLINE company, she replied O yes, I forgot.

So I ended buying PRIVATELY a full Quattro system from the online company for $176 plus an extra cushion for it (spare) at $54. Otherwise, to comply with the DME 6 month allowance to get a free mask under Medicare rental I would had to wait till May.

****************************************

At this point my situation is this:

I) I tried the Quattro but don't like it b/c I need to wear my upper denture with it to stop the leaks all around.
2 I don't like the Fisher & Peykel FF FlexiFit #432 b/c it does not have the forehead support to stop it digging into my nose bridge.
3) I don't like Resemed Mirage Gel Nasal mask b/c my mouth leaks.
4) What's left for me to try is Total Face mask and Dr. Steven Park's ideas to get off CPAP.

**************************************************

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
K0553 Combination oral/nasal mask, used with continuous positive airway pressure device

CPAP/BiPAP PART & ACCESSORY INSURANCE (HCPCS) CODES
A7031 Replacement Cushion for Full Face Mask
A7032 Replacement Cushion for Nasal Mask
A7033 Replacement Pillows for Nasal Mask
A7035 Headgear used with positive airway pressure device
A7036 Chinstrap used with positive airway pressure device
A7037 Tubing used with positive airway pressure device
A7038 Filter, disposable, used with positive airway pressure device
A7039 Filter, non-disposable (reusable), used with positive airway presssure device
A7045 Exhalation port with or without swivel used with accessories for positive airway pressure devices
A7046 Water chamber for humidifier, used with positive airway pressure device
E1399 Miscellaneous Durable Medical Equipment Items, Components and Accessories
K0554 Oral cushion for combination oral/nasal mask
K0555 Nasal pillows for combination oral/nasal mask
*****************************************


today I plan to inquire about it more and will report here.

[Slinky]

Yep, I just ran into a change myself. Medicare is my Primary and my secondary is thru UAW/GM and administered by BC/BS of MI. Since 2006 I've been allowed a new mask (and headgear) every 3 months. Once I found the Simplicity and got an extra (the Simplicity has lasted much longer than 3 months, and even longer than 6 months) I turned down a mask every 3 months until I realized that I was going to HAVE to go to a full face mask.

Even w/the full face mask I was allowed one every 3 months (complete). The second full face I tried was the ProBasics Zzz-Mask and once I got a second Zzz-Mask (which also lasts me more than 3 months) I turned down a mask every 3 months. My problem w/the Zzz-Mask has always been the darn headgear being too large and having to "modify" the headgear. The 'lab ratting" is easier to do w/a second set of hands - which I didn't have available when fitting the second Zzz-Mask. Now the headgear has stretched out enough that I'm having a REAL problem w/it riding on and hurting my ears.

I had just gotten this one last October so decided to try the Quattro FX and called to order it. Only to be told that I was now on a 6 month schedule for masks and not due until April. *sigh* We've also had some "adjustments" on our script meds the first of this year. We keep getting told there's no change in our coverage .... and then we get these changes in our script coverage and medication copays.

Still - we are MUCH MORE FORTUNATE than many so I'm not complaining .... well not too much anyway .... it sure beats having no coverage at all!!!

[Janknitz]

Slinky,

I just looked at all the transmittals on the CMS website (http://www.cms.gov)--this is Medicare's governing agency, and I can't find anything referring to a change in the replacement schedule for CPAP supplies. That doesn't mean it doesn't exist--it's hard to navigate that site and I MAY have missed it.

But before you take your DME's word for it on the replacement schedule, may I suggest:

1. Ask them to SHOW you the transmittal changing the frequency of mask replacements.
2. Calling Medicare and asking them (1-800-Medicare).
3. Try another DME--ask them what the Medicare replacement schedule is.

I would never trust a DME as far as I could throw them about coverage issues. Always confirm for yourself and ask them to show you EXACTLY where it says that. My guess is they don't make enough profit to be bothered with you.

Remember, even if two people have BCBS of Alabama, they could have different PLANS under that company, depending on their employer or private contract. So what is covered under one person's plan may NOT be covered under another.

Medicare is a little more uniform. Armed with the list of HCPC's codes, if you want to see how much Medicare has set as the fee for a piece of equipment in your state, you can download the fee schedule here: http://www.cms.gov/DMEPOSFeeSched/LSDME ... PerPage=10 Pay attention to the codes in the modifier column as they tell you if it's a purchase or a capped rental. Remember, UNDER FEDERAL LAW, the DME may not charge you more than 20% of the Medicare Allowable Fee for any itme on this list, including an expensive APAPwhen the DME only wants to give you a cheap data-less brick. It'f you are on Mediare, any additional charges for these items is FRAUDULENT!!!!!!!!!!!!!!!!!!!!!!!! (Exception for a Medicare Part C--HMO plan)

[Slinky]

Thanks, JanKnitz. Its always been confusing to me because even back in 2006 when I started on CPAP therapy Medicare's regulations were one MASK every three months BUT one HEADGEAR once every six months. Since my provider was providing one MASK AND HEADGEAR every 3 months I just kept my mouth shut and took advantage of the every 3 months w/o saying a word - except once I had what I needed I didn't want to run up costs for no reason.

If I don't like or don't agree w/what they tell me I always double check them. They really have been good to me. Of course, I'm also on 02 pretty much around the clock so I require more "attention" than most CPAP users - for which they get paid, of course.

And the local DME provider has nothing to do w/my script meds.

[avi123]

Thanks, JanKnitz. Its always been confusing to me because even back in 2006 when I started on CPAP therapy Medicare's regulations were one MASK every three months BUT one HEADGEAR once every six months. Since my provider was providing one MASK AND HEADGEAR every 3 months I just kept my mouth shut and took advantage of the every 3 months w/o saying a word - except once I had what I needed I didn't want to run up costs for no reason.

If I don't like or don't agree w/what they tell me I always double check them. They really have been good to me. Of course, I'm also on 02 pretty much around the clock so I require more "attention" than most CPAP users - for which they get paid, of course.

And the local DME provider has nothing to do w/my script meds.

I sent the above list to my DME and asked for their list of no- payment replacement items. I got a reply:

Dear Mr. Avi
I will get back to you tomorrow on the replacement parts. J

Janeknitz, your link doesn't work

Slinky, what's script meds? Do you suffer from COPD? As I understand it, Oxygen DMEs are separate from CPAPs and wheel chairs DMEs. As a past postal service employee, don't you have a Federal employees insurance?

[avi123]

Slinky, see the postage stamps used when I arrived in the US as an immigrant on a first preference visa:

http://www.google.com/images?hl=en&biw= ... =&aql=&oq=

[Slinky]

Ah, Avi!! I so well remember the 3 cent Lincoln - AND the Mighty Mack too. I bought a beautiful bi-centennial Mackinaw Bridge winter jacket when traveling to and thru the UP that year. Got a great price on it at the end of the year sales.

Since my husband had good family coverage thru the UAW/GM at a lesser copay than my copay would have been w/insurance thru the postal service I saw no need to enroll. There have been times now I wish I would have. But it just didn't make economic sense to do so. I had intended to enroll 5 years before I retired as you had to have been an enrollee for 4 years before retirement to carry that benefit into retirement. But the best laid plans of mice and men - and women too - I ended up having to retire earlier than I planned due to Crohn's disease.

And yup, I have COPD too. And many local DME providers cover both apnea supplies and respiratory (oxygen) supplies. In fact there are those that specialize in ONLY respiratory and OSA supplies.

Script meds are medications available only by prescription - vs OTC (over the counter) meds such as aspirin, Tylenol, etc.

[rested gal]

This may not apply to the BCBS reimbursements you all are discussing -- but might be of interest to those on just Medicare:

Medicare - finding replacement schedule for your area -- topic posted by rested gal -- Jan. 4, 2011
viewtopic.php?p=553220#p553220

[ResmedUser]

I gave up on insurance and DMEs. I took matters into my own hands and I pay for everything out of pocket. Its just between myself and my sleep doctor. That cuts out at least one layer of bureaucracy and bs (insurance) and really cuts out two layers of management (DME too). Its easier to deal with Internet suppliers than DMEs. This way I can tightly control what I get and what I dont get, when I want it. And no backtalk.

I strongly suggest you do the same. After a while, many OSA patients get fed up dealing with their insurance, their DMEs and turn to Internet supplers.

I am seriously thinking of doing the same with my psychiatrist as well, just pay out of pocket and bypass the insurance. Several top end psychopharmacologists in my area recently went out on their own and refuse to take health insurance anymore and only take patients who can pay out of pocket. That cuts out a lot of bs and allows the doctors to get in there and really do some real doctoring like they used to do. Modern era health insurance only holds doctors back and controls the treatments and tests they can administer and messes up the care patients get from their doctors.

Save the health insurance for major medical, hospitalisation, etc.

Mikey

[ResmedUser]

I just refuse to deal with DMEs and health insurance anymore. This coming Friday I am telling my brick and mortar DME "no more." Its over with. I am done with you. I am now buying all gear directly out of pocket and I do not want you communicating with my sleep medicine doctor anymore. I have fucking had it with health insurance, and brick and mortar DMEs.

Mikey

[Slinky]

Wow, Avi!! That is quite a collection! I used to get a plate of 4 of every new stamp, and then just of the new stamps I thought attractive. They were issuing so many it was just getting too expensive. They are just laying around the house here and there in waxed paper folders as I never did get around to organizing in any manner.

[Janknitz]

Janeknitz, your link doesn't work

Hmmm, try this:
http://www.cms.gov/DMEPOSFeeSched/LSDME ... PerPage=10

Sorry, for some reason the entire link didn't post yesterday.

Roby Sue, thanks for reposting how to get to the replacement schedule. I don't have time to look up every state, but I looked up my state, California, and there is NO change in the frequency of replacement for masks. An entire mask, INCLUDING head gear, every three months. Each person should follow those links to their own state's information, but I'm willing to bet a doughnut that there has been NO change in mask replacement frequency anywhere in the US. While each state's DME provisions are administered by different intermediaries, the rules are pretty uniform throughout the country (except for those 9 areas that are under that new DME system--haven't heard anything from people in those areas yet).

So, Slinky, find it for your state (HCPC's code for masks (Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap) is A0734. Then take it to the DME and smirk while they order your new mask.