CPAPtalk.com

Pugsy wrote:

Stevoreno_55 wrote:So would a basic "brick" CPAP machine also have the same billing code as a data capable CPAP machine?

Yes, a brick gets the same HCPCS code as the full efficacy data machines...E0601

Stevoreno_55 wrote:So are most DME's reluctant to provide a patient with an APAP machine if the reimbursement rate the DME will receive from a patient's insurance plan is no more than what they would receive for issuing a patient a basic CPAP machine?

Correct. APAPs cost the DME more money than the bricks cost them...they make more money selling bricks since the insurance company pays by HCPCS code and not by brand or model. The cost difference isn't a huge amount though but $50 or $100 multiplied by 100 or 1000 adds up.

Would that billing code amount be different from one insurance company to another or would the billing code amount be the same across the board no matter what a patient's insurance plan might be? For example if one patient had BCBS and another had United Health Care would the billable amount be the same?


Stevoreno_55
MS Gulf Coast
05/19/14

Stevoreno_55 wrote:Would that billing code amount be different from one insurance company to another or would the billing code amount be the same across the board no matter what a patient's insurance plan might be? For example if one patient had BCBS and another had United Health Care would the billable amount be the same?

The billing codes are all the same no matter which insurance company is involved...HCPCS billing codes are universal just like diagnosis codes.

Now what the insurance company might "allow" or pay for...that amount can and will vary among insurance companies. Some pay a lot more for the same billing code than another might pay.
DMEs typically bill a "pie in the sky" grossly inflated amount initially...insurance companies then will reduce that amount to the "allowable amount" or "usual and customary". Allowable amounts can vary among insurance companies and even among plans within a certain company.
So there is no set "allowable" amount that all insurance companies go by.