LCD/NCD Portal

L12934 HIGH FREQUENCY CHEST WALL OSCILLATION DEVICES

 

Region IV

DME

Jurisdiction C

 

08/05/2011

 

 

• For any item to be covered by Medicare, it must

o be eligible for a defined Medicare benefit category

o be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member

o Meet all other applicable Medicare statutory and regulatory requirements.

o 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.

o 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:

o Criterion 1, 2, or 3, and

o 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:

• Daily productive cough for at least 6 continuous months; or

• 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

o If these criteria are not met claims will be denied as not reasonable and necessary.

 

 

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 - 011.56

TUBERCULOUS BRONCHIECTASIS UNSPECIFIED EXAMINATION - TUBERCULOUS BRONCHIECTASIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR 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

WERDNIG-HOFFMANN DISEASE - ANTERIOR HORN CELL DISEASE UNSPECIFIED

340 MULTIPLE SCLEROSIS

344.00 - 344.09

QUADRIPLEGIA UNSPECIFIED - OTHER QUADRIPLEGIA

359.0 CONGENITAL HEREDITARY MUSCULAR DYSTROPHY

359.1 HEREDITARY PROGRESSIVE MUSCULAR DYSTROPHY

359.21 - 359.29

MYOTONIC MUSCULAR DYSTROPHY - OTHER SPECIFIED MYOTONIC DISORDER

359.4 - 359.6

TOXIC MYOPATHY - SYMPTOMATIC INFLAMMATORY MYOPATHY IN DISEASES CLASSIFIED ELSEWHERE

359.89 OTHER MYOPATHIES

494.0 BRONCHIECTASIS WITHOUT ACUTE EXACERBATION

494.1 BRONCHIECTASIS WITH ACUTE EXACERBATION

519.4 DISORDERS OF DIAPHRAGM

748.61 CONGENITAL BRONCHIECTASIS

 

 

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".

o It is expected that the patient's medical records will reflect the need for the care provided.

o 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.

o 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.

 

Sources of Information and Basis for Decision

 

A25519 - High Frequency Chest Wall Oscillation Devices- Policy Article- Effective January 2011

 

 

Local Coverage Determination (LCD) for High Frequency Chest Wall Oscillation Devices (L12934)