Local Coverage Article

High Frequency Chest Wall Oscillation Devices - Policy Article

A52494

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General Information

Article ID
A52494
Article Title
High Frequency Chest Wall Oscillation Devices - Policy Article
Article Type
Article
Original Effective Date
10/01/2015
Revision Effective Date
10/01/2021
Revision Ending Date
N/A
Retirement Date
N/A
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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.

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Article Guidance

Article Text

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES

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. Information provided in this policy article relates to determinations other than those based on Social Security Act §1862(a)(1)(A) provisions (i.e. “reasonable and necessary”).

High frequency chest wall oscillation devices are covered under the Durable Medical Equipment benefit (Social Security Act §1861(s)(6)). In order for a beneficiary’s equipment to be eligible for reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.

REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)

Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The link will be located here once it is available.

Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.

If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD, it will be eligible for coverage.


POLICY SPECIFIC DOCUMENTATION REQUIREMENTS

In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.

Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.

The diagnosis code that justifies the need for these items must be included on the claim.


MODIFIERS

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 Coverage Indications, Limitations, and/or Medical Necessity section of the related LCD have been met.

If all of the criteria in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD 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.

There must be information in the beneficiary’s medical record that describes in detail the underlying medical condition(s) that cause the accumulation of pulmonary secretions, the treatment interventions (for example, chest physiotherapy, postural drainage, medications used, mechanical modalities such as in-exsufflation devices (not all-inclusive)) and the effectiveness of the treatment. This information must be available upon request.

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

CODING GUIDELINES

HCPCS Code E0483 (HIGH FREQUENCY CHEST WALL OSCILLATION SYSTEM, INCLUDES ALL ACCESSORIES AND SUPPLIES, EACH) devices (HFCWO) use positive and negative pressure changes to augment peripheral and tracheal mucus movement towards the airway opening. This function is performed by extra-thoracic oscillations generated by forces external to the respiratory system. External chest wall oscillations are applied using a vest worn around the torso, which vibrates at variable frequencies and intensities, as set by the operator. E0483 devices may use differing technologies, e.g. air-pulse generators and an inflatable vest, an array of mechanical oscillators in a vest providing synchronized oscillation. E0483 is all-inclusive regardless of the technique used to produce HFCWO. 

HCPCS Code A7025 (HIGH FREQUENCY CHEST WALL OSCILLATION SYSTEM VEST, REPLACEMENT FOR USE WITH PATIENT OWNED EQUIPMENT, EACH) describes a complete replacement vest. This includes all components such as mechanical oscillators, electrical componentry, inflatable air sacs, connectors. Separate billing of vest components when an entire vest is replaced is incorrect coding – unbundling.

HCPCS Code A7026 (HIGH FREQUENCY CHEST WALL OSCILLATION SYSTEM HOSE, REPLACEMENT FOR USE WITH PATIENT OWNED EQUIPMENT, EACH) describes the tubing used with an air pulse generator type of HFCWO device.

HCPCS Code E0483 describes a complete system. Separate billing of A7025 and/or A7026 in combination with E0483 is incorrect coding – unbundling.

Code E0467 (HOME VENTILATOR, MULTI-FUNCTION RESPIRATORY DEVICE, ALSO PERFORMS ANY OR ALL OF THE ADDITIONAL FUNCTIONS OF OXYGEN CONCENTRATION, DRUG NEBULIZATION, ASPIRATION, AND COUGH STIMULATION, INCLUDES ALL ACCESSORIES, COMPONENTS AND SUPPLIES FOR ALL FUNCTIONS) describes a ventilator that integrates the function of multiple types of equipment into a single device. Code E0467 combines the function of a ventilator with those of any combination or all of the following:

  • Oxygen equipment
  • Nebulizer and compressor
  • Aspirator (suction device)
  • Cough stimulator (multiple products)
  • Positive airway pressure devices (PAP and RAD)
  • Custom fabricated oral appliances

The following high frequency chest wall oscillation devices HCPCS codes for individual items are included in the functionality of code E0467:

  • HCPCS codes E0483, A7025, A7026

For E0467 claims with dates of service before April 3, 2020:

Claims for any of the HCPCS codes listed above that are submitted on the same claim or that overlap any date(s) of service for E0467 is considered to be unbundling.

In addition, any claim for repair (HCPCS code K0739 for labor and any HCPCS code for replacement items) of beneficiary-owned equipment identified by HCPCS codes listed above is considered as unbundling if the date(s) of service for the repair overlaps any date(s) of service for code E0467.

Claims for code E0467 with a date(s) of service that overlaps date(s) of service for any of the following scenarios are considered as a claim for same or similar equipment when the beneficiary:

  • Is currently in a rental month for any of the items listed above
  • Owns any of the equipment listed above that has not reached the end of its reasonable useful lifetime.

For E0467 claims with dates of service on or after April 3, 2020:

Any claim for repair (HCPCS code K0739 for labor and any HCPCS code for replacement items) of beneficiary-owned equipment identified by HCPCS codes listed above is considered as unbundling if the date(s) of service for the repair overlaps any date(s) of service for code E0467.

Claims for code E0467 with a date(s) of service that overlaps date(s) of service in a rental month for any of the items listed above are considered as a claim for same or similar equipment.

Suppliers should contact the Pricing, Data Analysis, and Coding (PDAC) contractor for guidance on the correct coding of these items.

Coding Information

CPT/HCPCS Codes

Group 1

Group 1 Paragraph

 

Group 1 Codes

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph

The presence of an ICD-10 code listed in this section is not sufficient by itself to assure coverage. Refer to the LCD section on “Coverage Indications, Limitations, and/or Medical Necessity” for other coverage criteria and payment information.

 

Group 1 Codes
CodeDescription
A15.0 Tuberculosis of lung
B91 Sequelae of poliomyelitis
D81.810 Biotinidase deficiency
D84.1 Defects in the complement system
E84.0 Cystic fibrosis with pulmonary manifestations
E84.9 Cystic fibrosis, unspecified
G12.0 Infantile spinal muscular atrophy, type I [Werdnig-Hoffman]
G12.1 Other inherited spinal muscular atrophy
G12.20 Motor neuron disease, unspecified
G12.21 Amyotrophic lateral sclerosis
G12.22 Progressive bulbar palsy
G12.23 Primary lateral sclerosis
G12.24 Familial motor neuron disease
G12.25 Progressive spinal muscle atrophy
G12.29 Other motor neuron disease
G12.8 Other spinal muscular atrophies and related syndromes
G12.9 Spinal muscular atrophy, unspecified
G14 Postpolio syndrome
G35 Multiple sclerosis
G71.00 Muscular dystrophy, unspecified
G71.01 Duchenne or Becker muscular dystrophy
G71.02 Facioscapulohumeral muscular dystrophy
G71.09 Other specified muscular dystrophies
G71.11 Myotonic muscular dystrophy
G71.12 Myotonia congenita
G71.13 Myotonic chondrodystrophy
G71.14 Drug induced myotonia
G71.19 Other specified myotonic disorders
G71.20 Congenital myopathy, unspecified
G71.21 Nemaline myopathy
G71.220 X-linked myotubular myopathy
G71.228 Other centronuclear myopathy
G71.29 Other congenital myopathy
G71.3 Mitochondrial myopathy, not elsewhere classified
G71.8 Other primary disorders of muscles
G72.0 Drug-induced myopathy
G72.1 Alcoholic myopathy
G72.2 Myopathy due to other toxic agents
G72.89 Other specified myopathies
G73.7 Myopathy in diseases classified elsewhere
G82.50 Quadriplegia, unspecified
G82.51 Quadriplegia, C1-C4 complete
G82.52 Quadriplegia, C1-C4 incomplete
G82.53 Quadriplegia, C5-C7 complete
G82.54 Quadriplegia, C5-C7 incomplete
J47.0 Bronchiectasis with acute lower respiratory infection
J47.1 Bronchiectasis with (acute) exacerbation
J47.9 Bronchiectasis, uncomplicated
J98.6 Disorders of diaphragm
M33.02 Juvenile dermatomyositis with myopathy
M33.12 Other dermatomyositis with myopathy
M33.22 Polymyositis with myopathy
M33.92 Dermatopolymyositis, unspecified with myopathy
M34.82 Systemic sclerosis with myopathy
M35.03 Sjogren syndrome with myopathy
Q33.4 Congenital bronchiectasis

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

All ICD-10 codes that are not specified in the previous section.

Group 1 Codes

N/A

ICD-10-PCS Codes

N/A

Additional ICD-10 Information

N/A

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.

N/A

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 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.

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
10/01/2021 R13

Revision Effective Date: 10/01/2021
ICD-10-CM CODES THAT SUPPORT MEDICAL NECESSITY:
Revised: ICD-10-CM code G71.20 and M35.03 descriptions in Group 1 Codes, due to annual ICD-10-CM code updates

10/07/2021: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

10/01/2020 R12

Revision Effective Date: 10/01/2020
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: “etc.” from the not all-inclusive list of medical condition examples
CODING GUIDELINES:
Removed: “etc.” from the not all-inclusive list of differing technologies used by E0483 devices
Removed: “etc.” from the not all-inclusive list of components included in A7025

04/01/2021: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

10/01/2020 R11

Revision Effective Date: 10/01/2020
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Removed: ICD-10 code G71.2 from Group 1 codes, due to annual ICD-10 Code updates
Added: ICD-10 codes G71.20, G71.21, G71.220, G71.228, and G71.29 to Group 1 codes, due to annual ICD-10 Code updates

09/24/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

04/03/2020 R10

Revision Effective Date: 04/03/2020
CODING GUIDELINES:
Revised: Guidance for billing HCPCS code E0467 based on DOS

07/16/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2020 R9

Revision Effective Date: 01/01/2020
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO 42 CFR 410.38(g):
Removed: Statement that the diagnosis code, that justifies the need for the items, must be billed on the claim 
Removed: Section due to Final Rule 1713
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217):
Added: Section and related information based on Final Rule 1713
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: Statement that the diagnosis code, that justifies the need for the items, must be billed on the claim
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Covered” updated to “ICD-10 Codes that Support Medical Necessity”
ICD-10 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Not Covered” updated to “ICD-10 Codes that DO NOT Support Medical Necessity”

02/06/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2019 R8

Revision Effective Date: 01/01/2019
CODING GUIDELINES:
Added: E0467 Coding Guidelines

04/11/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2019 R7

Revision Effective Date: 01/01/2019
CODING GUIDELINES:
Revised: Code descriptor for E0483
ICD-10 CODES THAT ARE COVERED:
Added: All diagnosis codes formerly listed in the LCD
ICD-10 CODES THAT ARE COVERED:
Added: Notation excluding all unlisted diagnosis codes from coverage

02/14/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2018 R6

Revision Effective Date: 01/01/2018
CODING GUIDELINES:
Added: Coding guidelines for HCPCS codes E0483, A7025, A7026


04/05/18: At this time 21st Century Cures Act applies to new and revised LCDs that restrict coverage, which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2017 R5

Revision Effective Date: 01/01/2017
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:

Added: REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PERSUANT TO 42 CFR 410.38(g), previously in the Policy Specific Documentation Requirements section

11/23/17: At this time 21st Century Cures Act applies to new and revised LCDs that restrict coverage, which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2017 R4 Revision Effective Date: 01/01/2017
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: 42 CFR 410.38(g) and Modifier instructions
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements Language Article
07/01/2016 R3 Revision Effective Date: 07/01/2016
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised Standard Language to add Statutory Prescription (Order) Requirements, revised Face to Face and ACA requirements (Effective 04/28/2016)
07/01/2016 R2 Effective July 1, 2016 oversight for DME MAC Articles is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the Articles.
10/01/2015 R1 Revision Effective Date: 10/31/2014
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES
Removed: "When required by state law" from ACA new prescription requirements
Revised: Face-to-Face Requirements for treating practitioner

Associated Documents

Related National Coverage Documents
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Updated On Effective Dates Status
09/30/2021 10/01/2021 - N/A Currently in Effect You are here
03/26/2021 10/01/2020 - 09/30/2021 Superseded View
09/18/2020 10/01/2020 - N/A Superseded View
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Keywords

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