Last week, RAC Region D contractor HDI posted an approved audit issue for DME – Physician providers for overutilization of Positive Airway Pressure (PAP) and Respiratory Assist Device (RAD) accessories. Per the contractor’s issue description, utilization is listed in the Positive Airway Assist (PAP) and Respiratory Assist (RAD) devices Local Coverage Determination (LCD) policies. There is a common table that represents the usual maximum amount of accessories expected to be medically necessary. Quantities of supplies greater than those described in the policy as the usual maximum amounts will be denied as not medically necessary.

Accessories used for positive airway pressure devices have maximum amounts per month and their utilization can be found in in the Durable Medical Equipment (DME) Local Coverage Determination (LCD) policies Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L171) and Respiratory Assist Devices (L11493).


The following table represents the usual maximum amount of accessories expected to be reasonable and necessary: 


1 per 3 months


1 per 3 months


2 per 1 month


2 per 1 month


1 per 3 months


1 per 1 month


2 per 1 month


2 per 1 month


1 per 3 months


1 per 6 months


1 per 6 months


1 per 3 months


2 per 1 month


1 per 6 months


1 per 6 months

Billing for quantities of supplies greater than those described in the policy as the usual maximum amounts will be denied as not reasonable and necessary. 

I have written before stressing the importance of knowing your LCDs, since most automated RAC issues reference these policies where code combinations for medical necessity and utilization are spelled out. However,deciphering an LCD policy is not easy and may be a time-consuming task. Building system edits for billing and practice management software could also get complicated. Most providers turn to software vendors to do this for them. Vendors will keep up with the numerous monthly changes in LCDs that may occur. Vendors can build edits, such as alerts for providers to obtain signed ABNs for non-covered items, avoid overutilization, and bill with allowed CPT/HCPCS/ICD combinations. Complex edits can also check for patient billing history to avoid providing services or dispensing items that are only covered on certain time frames, for example, the PAP and RAD accessory HCPCS code A7046 that can only be billed every six months.

Web-based lookup tools from vendors allow for medical necessity checks to be done quickly and before a patient encounter or item is dispensed. Entering a code combination and finding out if they are listed in an LCD can be done in seconds, rather than spending time trying to locate the correct policy on CMS’ website.

RAC issues for the week of October 14 – October 18, 2013:

RAC Region A Performant

Outpatient Hospital

Once-per-day Procedure Codes – JK – Potential incorrect billing occurred for claims billed with CPT/HCPCS codes listed in Appendix E more than once per day, per beneficiary, per provider.

About the Author

Dr. Margaret Klasa is the medical director for Context4 Healthcare. She is responsible for the company’s business knowledge discovery unit for medical context as it relates to the daily development of data products and software for medical claims editing and coding, with an emphasis on clinical and regulatory guidelines for Medicare, Medicaid and commercial payors.

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