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Chip McDonald
Unread post  Post subject: Billing Codes and Terminology?  |  Posted: Thu Nov 29, 2018 10:57 am

Joined: Sat Jul 28, 2018 3:32 pm
Posts: 30
Location: North Augusta S.C. USA
PAP Mask: Dreamwear nasal cushion
PAP Machine: Resmed Airsense 10 Autoset climateline
Humidifier: Humidair
Pressure Setting: 8

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I got the following from my DME last month:

Airfit F20
A nasal cushion for my Dreamwear
2 filters for my Airsense 10 (that I own out of pocket)


I got the F20 in case I need it, if I get a cold etc. but routinely use the Dreamwear, sometimes a P10. So...

I asked if I could get replacement headgear for the Dreamwear, and said I couldn't because it's included in the F20. I explained I didn't want headgear for the F20 but for the Dreamwear, and was told the full face mask counts against the "replacement headgear" code?

I was also told I couldn't get a replacement "nasal application device" for the Dreamwear, since it is also against the code for the mask?


They also billed BCBS not as a full face mask, but as the replacement components separately. Which doesn't seem right to me, but I'm not a pro...?


So I'm going there now to get replacement cushions for the Dreamwear, and... I'd like to get replacement headgear for it as well, since mine shrunk considerably after washing it (?). And it'd be nice to have a new "nasal interface device", presuming that's the bit between the cushion and the headgear.

1) Should they have ran the billing separately like that?
2) If they had ran it as the "full face mask" code, would I have been eligible for a replacement "nasal mask interface" code?
3) Is Climateline tubing covered under the "tubing" code?
4) Does the "replacement nasal application device (1x year)" code get nulled by getting the full facemask?
5) What is code 7033, "replacement nasal 2 pairs every 30 days"?
6) Does the "replacement headgear 1x180 days" get counted against by the full face mask?
7) Isn't the code 7030 for "full face mask" for the headgear, cushion, "mask interface" together....?

It seems like I've lost my headgear code and the "nasal application device" replacement by them billing BCBS separately for "replacement" parts instead?


TAOT


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Pugsy
Unread post  Post subject: Re: Billing Codes and Terminology?  |  Posted: Thu Nov 29, 2018 1:20 pm
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Joined: Wed Aug 02, 2017 8:01 pm
Posts: 1327
PAP Mask: Bleep/DreamPort nasal mask
PAP Machine: ResMed AirSense 10 AutoSet for Her
Humidifier: ResMed AirSense 10
Pressure Setting: Depends on the machine as I actually have more than one

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Actually pretty much everything they did and said is correct.
See the replacement allowance schedule below...it's for Medicare but most insurance companies have adopted this schedule.

Headgear...only allowed once per 6 months and when you get any complete mask package that includes headgear...can't get a headgear for another mask at the same time because insurance only pays for 1 per 6 months.
And yes...they can legally separate the items and bill for each part...insurance actually expects it. There's no separate code for a complete mask package to be used.

There are 2 codes for tubing/hoses...one for regular non heated hose and one for the heated hose. Insurance pays a little more for heated hose because they do cost more.

When you get a new complete mask package...you can't at the same time get a replacement part for another mask and have insurance pay for it.

While logic might tell us that the 7030 code for full face mask should include all the components...it doesn't. It's essentially the frame only.
That's why all the parts get listed separately even though they come in one package.

Image


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Chip McDonald
Unread post  Post subject: Re: Billing Codes and Terminology?  |  Posted: Fri Nov 30, 2018 7:56 am

Joined: Sat Jul 28, 2018 3:32 pm
Posts: 30
Location: North Augusta S.C. USA
PAP Mask: Dreamwear nasal cushion
PAP Machine: Resmed Airsense 10 Autoset climateline
Humidifier: Humidair
Pressure Setting: 8

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Ah, ok, that's why I was inquiring about terminology. Effectively speaking then, "what the user would wear at night" collectively is:

7030 Full mask
7031 Replacement mask interface (cushion)
7035 Replacement headgear

= "CPAP mask"


What is a code 7034, "nasal application device" (listed as a mask on your list)? It's not the frame for something like a Dreamwear, or the assembly the cushions attach to on a P10?

Thanks again Pugsy


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Pugsy
Unread post  Post subject: Re: Billing Codes and Terminology?  |  Posted: Fri Nov 30, 2018 9:30 am
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Joined: Wed Aug 02, 2017 8:01 pm
Posts: 1327
PAP Mask: Bleep/DreamPort nasal mask
PAP Machine: ResMed AirSense 10 AutoSet for Her
Humidifier: ResMed AirSense 10
Pressure Setting: Depends on the machine as I actually have more than one

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Quote:
What is a code 7034, "nasal application device" (listed as a mask on your list)? It's not the frame for something like a Dreamwear, or the assembly the cushions attach to on a P10?


Actually that code is essentially any nasal mask frame minus the headgear. Might have a pillow/cushion included in the package that would still get billed out separately.
So the frame for the DreamWear.
And for the P10...the frame/short hose.
Or one of the other masks where the cushion clips into the plastic part...that's the frame..the plastic part.

Kind of a stupid code in my book...if a person wants to change masks in 3 months...they are going to need headgear which isn't included and isn't paid for.
And the headgear will wear out long before the frame will.

Mask manufacturers offer many different mask packages but DMEs don't always stock them.
My DME doesn't stock mask packages that don't include headgear and they won't let me get a mask using that code at 3 months.
Now some DMEs will go ahead and use that code and give people the complete package and either not bill out the headgear or be prepared to eat the cost when the insurance denies it if it hasn't been 6 months.


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Pugsy
Unread post  Post subject: Re: Billing Codes and Terminology?  |  Posted: Fri Nov 30, 2018 9:33 am
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Joined: Wed Aug 02, 2017 8:01 pm
Posts: 1327
PAP Mask: Bleep/DreamPort nasal mask
PAP Machine: ResMed AirSense 10 AutoSet for Her
Humidifier: ResMed AirSense 10
Pressure Setting: Depends on the machine as I actually have more than one

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Think of it this way...
pretty much all masks are composed of 3 parts.

Headgear
Frame
Cushion or pillow

They can be packaged with or without the headgear and/or even packaged with just the frame and no cushion or pillow.
The frame being whatever the cushion or pillow attaches to.


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Chip McDonald
Unread post  Post subject: Re: Billing Codes and Terminology?  |  Posted: Mon Dec 03, 2018 6:21 pm

Joined: Sat Jul 28, 2018 3:32 pm
Posts: 30
Location: North Augusta S.C. USA
PAP Mask: Dreamwear nasal cushion
PAP Machine: Resmed Airsense 10 Autoset climateline
Humidifier: Humidair
Pressure Setting: 8

Offline
Thanks again Pugsy...


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