L12934-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for High Frequency Chest Wall

Oscillation Devices (L12934)

Contractor Information

Contractor Name

CGS Administrators, LLC opens in new window

LCD Information

Document Information

LCD ID Number L12934

LCD Title

High Frequency Chest Wall Oscillation Devices

Contractor's Determination Number HFCW

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Alabama Arkansas Colorado Florida Georgia Louisiana Mississippi North Carolina New Mexico Oklahoma Puerto Rico

South Carolina Tennessee Texas

Virginia

Virgin Islands West Virginia

Oversight Region Region IV

DME Region LCD Covers Jurisdiction C

Original Determination Effective Date

For services performed on or after 10/01/2003 Original Determination Ending Date

Revision Effective Date

For services performed on or after 08/05/2011

Revision Ending Date

CMS National Coverage Policy

Indications and Limitations of Coverage and/or Medical Necessity

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following indications and limitations of coverage and/or medical necessity.

For an item to be covered by Medicare a written signed and dated order must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as not reasonable and necessary.

High frequency chest wall oscillation devices (HFCWO) (E0483) are covered for patients who meet:

A. Criterion 1, 2, or 3, and

B. Criterion 4

There is a diagnosis of cystic fibrosis (ICD-9 277.00, 277.02)

There is a diagnosis of bronchiectasis (ICD-9 011.50-011.56, 494.0, 494.1, 748.61) which has been confirmed by a high resolution, spiral, or standard CT scan and which is characterized by:

a. Daily productive cough for at least 6 continuous months; or

b. Frequent (i.e., more than 2/year) exacerbations requiring antibiotic therapy.

Chronic bronchitis and chronic obstructive pulmonary disease (COPD) in the absence of a confirmed diagnosis of bronchiectasis do not meet this criterion.

The patient has one of the following neuromuscular disease diagnoses: Post-polio (138)

Acid maltase deficiency (277.6)

Anterior horn cell diseases (335.0-335.9) Multiple sclerosis (340)

Quadriplegia (344.00-344.09)

Hereditary muscular dystrophy (359.0, 359.1)

Myotonic disorders (359.21-359.29)

Other myopathies (359.4, 359.5, 359.6, 359.89) Paralysis of the diaphragm (519.4)

There must be well-documented failure of standard treatments to adequately mobilize retained secretions.

If all of the criteria are not met, the claim will be denied as not reasonable and necessary.

It is not reasonable and necessary for a patient to use both an HFCWO device and a mechanical in-exsufflation device (E0482).

Replacement Supplies, A7025 and A7026, used with patient owned equipment are covered if the patient meets the criteria listed above for the base device, E0483 If these criteria are not met claims will be denied as not reasonable and necessary.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes

The appearance of a code in this section does not necessarily indicate coverage.

HCPCS MODIFIERS:

EY - No physician or other health care provider order for this item or service

GA - Waiver of liability statement issued as required by payer policy, individual case GZ - Item or service expected to be denied as not reasonable and necessary

KX -Specific required documentation on file

HCPCS CODES

A7025 HIGH FREQUENCY CHEST WALL OSCILLATION SYSTEM VEST, REPLACEMENT FOR USE WITH PATIENT OWNED EQUIPMENT, EACH

A7026 HIGH FREQUENCY CHEST WALL OSCILLATION SYSTEM HOSE, REPLACEMENT FOR USE WITH PATIENT OWNED EQUIPMENT, EACH

E0483 HIGH FREQUENCY CHEST WALL OSCILLATION AIR-PULSE GENERATOR SYSTEM, (INCLUDES HOSES AND VEST), EACH

ICD-9 Codes that Support Medical Necessity

The presence of an ICD-9 code listed in this section is not sufficient by itself to assure coverage. Refer to the section on “Indications and Limitations of Coverage and/or Medical Necessity” for other coverage criteria and payment information.

011.50 -

TUBERCULOUS BRONCHIECTASIS UNSPECIFIED EXAMINATION - TUBERCULOUS

011.56 opens in new BRONCHIECTASIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR

window

HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS

(INOCULATION OF ANIMALS)

138 LATE EFFECTS OF ACUTE POLIOMYELITIS

277.00 CYSTIC FIBROSIS WITHOUT MECONIUM ILEUS

277.02 CYSTIC FIBROSIS WITH PULMONARY MANIFESTATIONS

277.6 OTHER DEFICIENCIES OF CIRCULATING ENZYMES 335.0 - 335.9 opens

in new window WERDNIG-HOFFMANN DISEASE - ANTERIOR HORN CELL DISEASE UNSPECIFIED

340 MULTIPLE SCLEROSIS

344.00 -

344.09 opens in new QUADRIPLEGIA UNSPECIFIED - OTHER QUADRIPLEGIA window

359.1 CONGENITAL HEREDITARY MUSCULAR DYSTROPHY

359.2 HEREDITARY PROGRESSIVE MUSCULAR DYSTROPHY

MYOTONIC MUSCULAR DYSTROPHY - OTHER SPECIFIED MYOTONIC DISORDER

359.21 -

359.29 opens in new window

359.4 - 359.6 opens TOXIC MYOPATHY - SYMPTOMATIC INFLAMMATORY MYOPATHY IN DISEASES CLASSIFIED

in new window

ELSEWHERE

359.89 OTHER MYOPATHIES

494.1 BRONCHIECTASIS WITHOUT ACUTE EXACERBATION

494.2 BRONCHIECTASIS WITH ACUTE EXACERBATION

519.4 DISORDERS OF DIAPHRAGM

748.61 CONGENITAL BRONCHIECTASIS

Diagnoses that Support Medical Necessity Refer to the previous section.

ICD-9 Codes that DO NOT Support Medical Necessity

All ICD-9 codes that are not specified in the previous section.

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

All diagnoses that are not specified in the previous section. Back to Top

General Information

Documentations Requirements

Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider". It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request. Items billed before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code.

The ICD-9 code that justifies the need for these items must be included on the claim.

KX, GA, AND GZ MODIFIERS:

Suppliers must add a KX modifier to codes for an HFCWO device and accessories only if all of the criteria in the Indications and Limitations of Coverage and/or Medical Necessity section of this policy have been met.

If all of the criteria in the Indications and Limitations of Coverage and/or Medical Necessity section have not been met, the GA or GZ modifier must be added to the code. When there is an expectation of a denial as not reasonable and necessary, suppliers must enter GA on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or GZ if they have not obtained a valid ABN.

Claim lines billed without a KX, GA, or GZ modifier will be rejected as missing information.

Refer to the Supplier Manual for more information on documentation requirements.

Appendices

Utilization Guidelines Refer to Indications and Limitations of Coverage and/or Medical Necessity.

Sources of Information and Basis for Decision Advisory Committee Meeting Notes

Start Date of Comment Period 09/06/2002

End Date of Comment Period 10/25/2002

Start Date of Notice Period 06/01/2003

Revision History Number 005

Revision History Explanation Revision Effective Date: 01/01/2011 INDICATIONS AND LIMITATIONS OF COVERAGE:

Revised: Preamble language HCPCS CODES AND MODIFIERS:

Revised: GA modifier

Revision Effective Date: 10/01/2009 INDICATIONS AND LIMITATIONS OF COVERAGE:

Clarified: Coverage criterion #2. HCPCS CODES AND MODIFIERS:

Added: GA, GZ Revised: KX

DOCUMENTATION REQUIREMENTS:

Added: Instructions for GA and GZ modifiers

Revision Effective Date: 10/01/2008 INDICATIONS AND LIMITATIONS OF COVERAGE:

Added: Coverage for specified neuromuscular diseases.

Added: Statement about concurrent use of mechanical in-exsufflation device.

ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY: Added: ICD-9 codes for neuromuscular diseases.

03/01/2008 In accordance with Section 911 of the Medicare Modernization Act, this policy was transitioned to DME MAC CIGNA Government Services (18003) LCD L11517 from DME PSC TrustSolutions (77012) LCD L11517.

Revision Effective Date: 07/01/2007 INDICATIONS AND LIMITATIONS OF COVERAGE:

Removed: DMERC references DOCUMENTATION REQUIREMENTS:

Removed: DMERC references

Removed: KX modifier requirements for claim submission SOURCES OF INFORMATION:

Removed: References

06/01/2007 In accordance with Section 911 of the Medicare Modernization Act of 2003, Virginia and West Virginia were transitioned from DME PSC TriCenturion (77011) to DME PSC TrustSolutions (77012).

03/01/2006 In accordance with Section 911 of the Medicare Modernization Act of 2003, this policy was transitioned to DME PSC TrustSolutions (77012) from DMERC Palmetto GBA (00885).

Revision Effective Date: 04/01/2005 LMRP converted to LCD and Policy Article

INDICATIONS AND LIMITATIONS OF COVERAGE AND/OR MEDICAL NECESSITY:

Revised coverage criteria for to allow conventional CT scan for diagnosis of bronchiectasis

Revision Effective Date: 10/01/2003 CODING GUIDELINES:

Added bundling language for A7025 and A7026.

08/05/2011 - The Jurisdiction C contractor adopted a new business name. This LCD revision only includes the change from CIGNA Government Services to CGS Administrators, LLC. No coverage information was included in this revision and no provider action is needed regarding this revision.

Reason for Change Maintenance (annual review with new changes, formatting, etc.)