Respiratory Assist Devices

New Users (Months 1-3)

 

For Dates of Service > 10/1/99

 

Group 1

Group 2

Group 3

Group 4

Restrictive Thoracic Disorders

Diagnosis

Progressive Neuromuscular

Severe Thoracic Cage Abnormality

Severe COPD

Central Sleep Apnea (CSA)

Obstructive Sleep Apnea (OSA)

Awake ABG (breathing FI02)

PaC02 > 45 mm Hg or

PaC02 > 45 mm Hg or

PaC02 > 52 mm Hg and

N/A

N/A

Sleep Oximetry

02 saturation < 88% (for at least 5 continuous minutes while breathing usual FI02) or

02 saturation < 88% (for at least 5 continuous minutes while breathing usual FI02)

02 saturation < 88% (for at least 5 continuous minutes on 2 LPM or usual FI02 (whichever is higher) and

02 saturation < 88% (for at least 5 continuous minutes while breathing usual FI02)

N/A

Pulmonary Function Test (PFT)

Maximal inspiratory pressure < 60 cm H20 or FVC <50% predicted

N/A

N/A

N/A

N/A

Facility Based Polysomnogram

N/A

N/A

N/A

CSA

OSA

Other

COPD does not contribute significantly to pulmonary limitation

Prior to initiating therapy, OSA and treatment with CPAP was considered and ruled out

Exclude OSA and rule out CPAP and significant improvement with RAD

CPAP (E0601) tried and proven ineffective

Device Covered

K0532 or K0533 x 3 months

K0532 or K0533 x 3 months

K0532 x 3 months. K0533 after 2 months with additional criteria.

K0532 or K0533 x 3 months

K0532 x 3 months or downcoded to E0601 K0533 after 2 months not medically necessary

ZX Modifier

If < 90 days = MD order with covered diagnosis.

If > 90 days = MD statement and beneficiary statement.

If < 90 days = N/A If > 90 days: K0532 = MD order and    covered diagnosis K0533 = N/A

Patient’s Medical Record

Symptoms characteristic with sleep associated with hypoventilation (e.g. daytime sleepiness, excessive fatigue, morning

headache, cognitive dysfunction and/or dyspnea)

 

Respiratory Assist Devices

New Users ( > 4 months)

 

For Dates of Service > 10/1/99

 

Group 1

Group 2

Group 3

Group 4

Restrictive Thoracic Disorders

Diagnosis

Progressive Neuromuscular

Severe Thoracic Cage Abnormality

Severe COPD

Central Sleep Apnea (CSA)

Obstructive Sleep Apnea (OSA)

Patient on K0532 or K0533 prior to 10/1/99

Statement from MD

. (Using 4 hours in 24 hours)

.Patient benefiting from use

.Beneficiary Statement

If using < 3 months:Statement from MD.

. Using 4 hours in 24 hours

. Patient benefiting from use

Beneficiary StatementIf using > 3 months:

N/A

Re-evaluation

Between 61st and 90th day of initiating therapy

MD Statement

Signed and dated statement from treating MD

·Using 4 hours in 24 hours

·Patient benefiting from use

N/A

N/A

If change from K0532 to K0533

·No benefit from K0532

·Compliant use of K0532 > 61 days

N/A

N/A

> 60 days Beneficiary Statement

Discontinue billing if applicable

Yes

Repeat Awake ABG

No sooner than day 61 after initiation of compliant use of K0532

PaC02 > 52 breathing FI02 and

Repeat Sleep Oximetry

No sooner than day 61 after initiation of compliant use of K0532 while on K0532 device

Saturation < 88% 5 minutes on 2 LPM or FI02 (whichever is higher)

ZX Modifier

MD Statement

Beneficiary Statement

Repeat ABG

Repeat oximetry 


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