Respiratory Assist Devices - Policy Article - Effective October 2015

Revision Effective Date: 06/09/2025
MODIFIERS:
Removed: KX modifier billing instructions regarding claims for the first through third months, the fourth month, and any month thereafter
Revised: KX modifier instruction to include use when coverage criteria is met in the “Coverage Indications, Limitations, and/or Medical Necessity” section in the related LCD and/or in the related NCD 240.9 have been met and evidence of such is retained in the supplier’s files and available to the DME MAC upon request
Removed: "In all of the situations above describing use of the KX modifier" from the GA and GZ modifiers instructions
RELATED NATIONAL COVERAGE DOCUMENTS:
Added: NCD 240.9


10/09/2025: 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.

Revision Effective Date: 08/08/2021
CODING GUIDELINES:
Removed: Coding and billing information pertaining to multifunction ventilators coded E0467
CODING VERIFICATION REVIEW:
Removed: Section header and PDAC coding verification review (CVR) information, including CVR information pertaining to products coded E0467


05/16/2024: 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.

Revision Effective Date: 08/08/2021
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 FED. REG VOL 217):
Removed: “The link will be located here once it is available.”
Added: “The required Face-to-Face Encounter and Written Order Prior to Delivery List is available here.” with a hyperlink to the list


04/14/2022: 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.

Revision Effective Date: 08/08/2021
CODING GUIDELINES:
Revised: Coding instructions for multifunction ventilators (E0467) (Effective 01/01/2019)
CODING VERIFICATION REVIEW:
Added: Section header and PDAC coding verification review (CVR) information
Added: CVR requirement for products coded E0467


11/11/2021: 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.

Revision Effective Date: 08/08/2021
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: Language regarding no aspect of a home sleep test may be performed by a DME supplier
Revised: Language regarding a liner used in conjunction with a PAP mask are noncovered
Added: Language regarding monitoring devices are statutorily non-covered (previously under Coding Guidelines)
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Revised: Coverage, coding and documentation requirements reference from “see below” to “see Coverage Indications, Limitations, and/or Medical Necessity section of the related LCD”
MODIFIERS:
Removed: Reference to “Group I – IV” from KX modifier section as groups are no longer referenced in the Coverage Indications, Limitations, and/or Medical Necessity section of the related LCD
Revised: Typographical errors to add commas after “Limitations” when referencing “Coverage Indications, Limitations, and/or Medical Necessity”
Added: Statement of claim line rejection if billed without GA, GZ or KX modifier (previously noted in the LCD)
CODING GUIDELINES:
Revised: Language related to HCPCS code A9279 and monitoring devices and services
06/24/2021: 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.

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.

Revision Effective Date: 01/01/2020
 NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
 Removed: REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO 42 CFR 410.38(g) section
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

 MODIFIERS:
 Revised: “physician” to “practitioner”
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”


02/27/2020: 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.

Revision Effective Date: 01/01/2019
 CODING GUIDELINES:
Revised: E0467 Coding Guidelines to include custom fabricated oral appliances


04/04/2019: 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.

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


03/07/2019: 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.

Revision Effective Date: 01/01/2017
 NON-MEDICAL NECESSITY COVERAGE & PAYMENT RULES:
 Added: Direction for REPLACEMENT OF ACCESSORIES FOR MEDICARE-PAID, BENEFICIARY-OWNED EQUIPMENT


06/14/2018: 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.

Revision Effective Date: 01/01/2017
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES
Added: 42 CFR 410.38(g) language, previously in POLICY SPECIFIC DOCUMENTATION REQUIREMENTS section.


04/05/2018: 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 no a local coverage determination.

Revision Effective Date: 01/01/2017
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: 42 CFR 410.38(g) and Modifiers requirements
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements Language Article

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.

Revision Effective Date: 11/05/2015
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: Standard Documentation language to remove start date verbiage from Prescription Requirements

Revision Effective Date: 12/01/2014 (May 2015 Publication)
NON-MEDICAL NECESSITY COVERAGE & PAYMENT RULES:
Added: Non-coverage statement for liners used in conjunction with a PAP mask
Removed: “When required by state law” from ACA new prescription requirements
CODING GUIDELINES:
Added: Coding guidelines for liners used with PAP mask based on DME MAC article posted on February 13, 2014
Added: Coding guidelines for Monitoring Technology based on DME MAC article posted on November 15, 2013

Revision Effective Date: 10/01/2015
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: ACA 6407 prescriber requirements