LCD Reference Article Billing and Coding Article

Billing and Coding: Surgical Treatment of Obstructive Sleep Apnea (OSA)

A56905

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A56905
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Surgical Treatment of Obstructive Sleep Apnea (OSA)
Article Type
Billing and Coding
Original Effective Date
08/29/2019
Revision Effective Date
07/27/2023
Revision Ending Date
N/A
Retirement Date
N/A

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CMS National Coverage Policy

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Article Guidance

Article Text

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.

  1. 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.
  2. 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.
  3. 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.
  4. Submucosal ablation of the tongue base, radiofrequency, one or more sites, per session. (41530) will be denied as investigational and experimental.

Response To Comments

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Coding Information

Bill Type Codes

Code Description

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Revenue Codes

Code Description

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(2 Codes)
Group 1 Paragraph

Note: Diagnosis codes must be coded to the highest level of specificity.
These are the only covered diagnoses for CPT codes 21685, and 42145. This list will not address the other listed CPT/HCPCS services/procedures.

Group 1 Codes
Code Description
G47.30 Sleep apnea, unspecified
G47.33 Obstructive sleep apnea (adult) (pediatric)

Group 2

(1 Code)
Group 2 Paragraph

These are the only covered diagnosis codes for CPT code 41512:
Both the primary diagnosis code and at least one of the following secondary codes must be present on the claim.

Primary diagnosis code for CPT codes 41512:

Group 2 Codes
Code Description
G47.33 Obstructive sleep apnea (adult) (pediatric)

Group 3

(2 Codes)
Group 3 Paragraph

Secondary diagnosis code for CPT codes 41512:

Note: that diagnosis code K14.8 may be used only for tongue hypertrophy. Each of the conditions must be documented in the medical record which must be made available to Medicare upon request.

Group 3 Codes
Code Description
K14.8 Other diseases of tongue
Q38.2 Macroglossia
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-PCS Codes

Group 1

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Group 1 Codes

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Additional ICD-10 Information

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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.

Code Description

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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.

Code Description

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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
07/27/2023 R4

Posted 07/27/2023 Under Group 1 Codes Group 1 Paragraph removed duplicate statement “Diagnosis codes must be coded to the highest level of specificity.” Review completed 06/13/2023.

01/01/2023 R3

Posted 1/26/2023-Description change to Group 1 Code 42999 effective 01/01/2023 due to the 2023 Q1 CPT/HCPCS Code Update.

07/29/2021 R2

07/29/2021 Review completed 6/18/2021.

11/01/2019 R1

Content has been moved to the new template.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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Public Versions
Updated On Effective Dates Status
07/19/2023 07/27/2023 - N/A Currently in Effect You are here
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