Local Coverage Article:
Billing and Coding: Surgical Treatment of Obstructive Sleep Apnea (OSA) (A56905)
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General Article Information Table
Billing and Coding: Surgical Treatment of Obstructive Sleep Apnea (OSA)
Billing and Coding
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Original Effective Date
Revision Effective Date
CMS National Coverage Policy
The billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD L34526.
Sleep-Disordered Breathing, often referred to as Obstructive Sleep Apnea (OSA), is characterized by frequent episodes of hypopnea or apnea during sleep. Multiple detrimental physiologic changes may result from these hypopneic and apneic episodes. Non-surgical and surgical approaches to obstructive apnea and hypopnea have been developed.
The following procedures are not covered at this time.
- Laser-assisted uvulopalatoplasty (LAUP) is not covered at this time since it is not considered effective for OSA. LAUP must not be billed as 42145, Palatopharyngoplasty (e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty). This code is not appropriate for this procedure. If LAUP is billed for denial purposes, it should be coded as 42299, (unlisted procedure, palate, uvula) with "LAUP" in the electronic narrative 2400/SV101-7 equivalent to line 19 of the CMS 1500 form. The claim will be denied as not proven effective.
- Somnoplasty™ is a trade name for palate reduction with the Somnoplasty™ System of Somnus Medical Systems. This is not a term recognized by this Contractor as a covered procedure under Medicare Part B. Therefore Somnoplasty™ must not be billed as 42145. This code is not appropriate for this procedure. If Somnoplasty™ is billed for denial purposes, it should be coded as 42299, (unlisted procedure, palate, uvula) with "Somnoplasty™" in the electronic narrative 2400/SV101-7 equivalent to line 19 of the CMS 1500 form. This claim will be denied as not proven effective.
- The Pillar Procedure™ is a trade name for palatal implants. Palatal implants have not been shown effective for the treatment of obstructive sleep apnea and are not covered. This procedure should be billed by the physician as 42299 (unlisted procedure, palate, uvula) with “Pillar Procedure™” or “palatal implant” in the electronic narrative 2400/SV101-7 equivalent to line 19 of the CMS 1500 form. This claim will then be denied as not proven effective. Hospital outpatient departments would use code C9727.
- Submucosal ablation of the tongue base, radiofrequency, one or more sites, per session. (41530) will be denied as investigational and experimental.
Group 1 Paragraph: N/A
Group 1 Codes:
CPT/HCPCS Codes Information Table
||APPLICATION OF INTERDENTAL FIXATION DEVICE FOR CONDITIONS OTHER THAN FRACTURE OR DISLOCATION, INCLUDES REMOVAL
||RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION (EG, FOR LONG FACE SYNDROME), WITHOUT BONE GRAFT
||RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS)
||RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITH INTERNAL RIGID FIXATION
||OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH GENIOGLOSSUS ADVANCEMENT
||HYOID MYOTOMY AND SUSPENSION
||SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD
||ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); INTRAMURAL (IE, SUBMUCOSAL)
||TRACHEOSTOMY, PLANNED (SEPARATE PROCEDURE);
||TRACHEOSTOMY, FENESTRATION PROCEDURE WITH SKIN FLAPS
||TONGUE BASE SUSPENSION, PERMANENT SUTURE TECHNIQUE
||SUBMUCOSAL ABLATION OF THE TONGUE BASE, RADIOFREQUENCY, 1 OR MORE SITES, PER SESSION
||PALATOPHARYNGOPLASTY (EG, UVULOPALATOPHARYNGOPLASTY, UVULOPHARYNGOPLASTY)
||UNLISTED PROCEDURE, PALATE, UVULA
||INSERTION OF IMPLANTS INTO THE SOFT PALATE; MINIMUM OF THREE IMPLANTS
Group 1 Paragraph: N/A
Group 1 Codes: N/A
ICD-10 Codes that Support Medical Necessity
ICD-10 Codes that DO NOT Support Medical Necessity
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
article does not apply to that Bill Type. Complete absence of all Bill Types indicates
that coverage is not influenced by Bill Type and the article should be assumed to
apply equally to all claims.
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 article, 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 article should be assumed to apply equally to all Revenue Codes.
Group 1 Paragraph: N/A
Group 1 Codes: N/A
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Related Local Coverage Document(s)
Related National Coverage Document(s)
Statutory Requirements URL(s)
Rules and Regulations URL(s)
CMS Manual Explanations URL(s)
Updated on 10/31/2019 with effective dates 11/01/2019 - N/A