Is there a HCPCS code...

nomad · Post by **nomad** » Tue Jul 25, 2006 12:18 pm

... for the Encore Pro Software & Smart Card Reader? I'm trying to figure out if my insurance will cover this seeing as how my DME provider (sleep lab) can't interpret the data from my card. When I asked about the specifics of my treatment, they couldn't tell me a whole lot more than "you're compliant this much and your indexes are this..." Nothing about "you need to do this" or "we need to adjust this."

I refuse to drive 45 minutes each way (during work hours) just to get him to tell me the basics without any real feedback or suggestions on an occasional basis.

mousetater · Post by **mousetater** » Tue Jul 25, 2006 12:46 pm

I have not heard of anyone who has had the smart card software and reader covered by insurance. I know my insurance didn't cover mine.

Wulfman · Post by **Wulfman** » Tue Jul 25, 2006 12:47 pm

This is one of those things we've all had to purchase out-of-pocket.....the card reader and software are only SUPPOSED to be used by DMEs, RTs and doctors.
When you consider YOUR time, travel, etc......and the fact that they're probably charging your insurance for reading your card (just to see the compliance info), it makes the cardreader and software pretty cheap to monitor your own therapy.

https://www.cpap.com/productpage/respir ... eader.html

Best wishes,

Den

krousseau · Post by **krousseau** » Tue Jul 25, 2006 12:52 pm

BC/BS FEP wouldn't spring for it. My titration study just met the duration set by insurance (and Medicare) to reimburse for the CPAP equipment and I was starting a sinus infection. I thought it was pretty shaky info to use in Rxing treatment. Since it's a 3 1/2 hour trip each way for me I wanted the software to see how I was doing at the prescribed pressures.

jkeene · Post by **jkeene** » Tue Jul 25, 2006 2:31 pm

You could try code E1399 (miscellaneous supplies), and then write a two-page narrative documenting what it is, what it's for, who it's made by, the manufacturer's phone number and part numbers.

I got Aetna to pay for the 12v adaptor using that code. Had it on an invoice with some mask supplies. The first time they held the claim for review the CSR said in a very skeptical tone "I don't think they're going to pay for you to hook up a CPAP to a cigarette lighter." My strategy was to fax them ever more documentation every 2-3 weeks until they caved. I was up to eleven pages, including the original sleep study, when they gave in.

Guest · Post by **Guest** » Tue Jul 25, 2006 5:38 pm

[quote="Wulfman"]the fact that they're probably charging your insurance for reading your card (just to see the compliance info), it makes the cardreader and software pretty cheap to monitor your own therapy.
Best wishes,

Den

Wulfman · Post by **Wulfman** » Tue Jul 25, 2006 7:10 pm

Anonymous wrote:
Wulfman wrote:the fact that they're probably charging your insurance for reading your card (just to see the compliance info), it makes the cardreader and software pretty cheap to monitor your own therapy.
Best wishes,

Den

Insurance companies are not charged by providers to read a card.

Well, according to this .pdf file from the Respironics website, there are codes available for doing just that. I'll let you folks decide......

http://reimbursement.respironics.com/do ... lHints.pdf

Do they ACTUALLY charge? I dunno. But, the way I read the document, they CAN.

Den

nomad · Post by **nomad** » Tue Jul 25, 2006 7:49 pm

mousetater wrote:I have not heard of anyone who has had the smart card software and reader covered by insurance. I know my insurance didn't cover mine.

That bites. I look at our nightly therapy similar to that of a diabetic testing and treating themselves... not exactly the same, but close. A person that's newly diagnosed with diabetes has a certain learning curve when it comes to self testing and self treatment. So do we. They still need to visit their doctor periodically for their condition. So do we (I guess). Most insurance will cover a good portion (if not all) of their supplies... but not for us. They have support (and information) all over the web, but not for us.

I'm beginning to realize OSA is the red headed step child of the medical industry. My doctor had offered to sit down with me to discuss surgical remedies for my OSA, but has yet to ask or offer to discuss with me how my CPAP therapy is going. As far as this thing goes... I have a feeling I'm on my own (with y'alls help from time to time of course).

Wulfman · Post by **Wulfman** » Tue Jul 25, 2006 8:44 pm

If anybody wants to look at any of these other related HCPCS documents, you can look here:

http://reimbursement.respironics.com/FilingClaims.asp

Den

KansasRT · Post by **KansasRT** » Wed Jul 26, 2006 7:42 am

Just because there is a billing code doesn't mean that it is a reimbursable service. NO DME provider should bill you to read your smart card. If you can't afford a card reader and software, ask your DME if they will mail you a replacement card so that you can send yours in and not be without a card. There is no reason why they wouldn't also send you a copy of your download information. I live in the real world and I am sure that there are DME companies that will not mail a card or give the patient a copy of their download without charging. As far as DME companies requiring that you rent your machine for 10-15 months, no DME would require themselves to bill an insurance company every month for a year and wait 30-90 days for a payment if they could avoid it. Most of those requirements are set by your insurance company.(That's not to say that there aren't some DME companies out there that set their own rules.)

cwsanfor · Post by **cwsanfor** » Sun Aug 27, 2006 6:33 am

I submitted a reimbursement request to my insurer, the North Carolina State Health Plan. It was initially denied. I submitted an appeal, saying:

"This is to appeal the denial of payment for an xPAP data card, data reader, and software, claim and denial attached, for the following reasons:

1. This device was prescribed by my physician (see attached prescription).
2. This device has numerous appropriate billing codes (see attached “Helpful Hints for Filing Encore Pro Software Software with SmartCard” (also at http://reimbursement.respironics.com/do ... rsement%22).
3. This device does not go to patient comfort or convenience, but rather facilitates correct monitoring of symptoms and treatment, such as changed pressure requirements.
4. This device usually saves many times its cost by avoiding repeat sleep studies.
5. This device has no use other than xPAP management.
6. By purchasing this device online and requesting reimbursement I save the taxpayer money compared to purchasing through a bricks and mortar DME vendor.

I attach an example of just one chart from the software, as an example of the type data it produces. If I may provide additional information, please so advise.

Thank you for your reconsideration of this matter."

I just got a reply saying:

"Your request for appeal was made when the Encore Pro Software and card readers (sic) were prescribed by your physician. You indicated that this device does not go to patient convenience or comfort, but rather facilitates correct monitoring of symptoms and treatment... The first level grievance committee carefully reviewed your case and it is our decision to overturn the denial. The above claim has been reprocessed. Benefits will be provided based on your coverage and eligibility at the time services were provided."

Woot Woot!

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CPAPopedia Keywords Contained In This Post (Click For Definition): Encore Pro, DME, Prescription

Is there a HCPCS code...

Is there a HCPCS code...

E1399

Software and reader is reimbursed by some insurance