National Government Services (NGS), the Jurisdiction B Durable Medical Equipment Administrative Contractor has identified an increase in the number of requests for reopenings for Continuous Positive Airway Pressure (CPAP) device (E0601) claims. It states, “While the reopening process is available to correct minor errors and omissions it is more cost effective to submit the claim correctly the first time.”

NGS also declares:

Effective April 1, 2014, National Government Services will begin rejecting claims for CPAP equipment and accessories with American National Standards Institute (ANSI) code CO-4, “procedure code is inconsistent with the modifier used, or a required modifier is missing.” when the International Classification of Diseases, 9th Revision (ICD-9) code indicated on the claim is something other than ICD-9 code 327.23-Obstructive sleep apnea (adult) (pediatric) and the KX modifier is present.

The PAP device LCD require the presence of a KX, GA, GZ, or GY modifier to indicate whether the coverage criteria outlined within that policy are or are not met and whether an Advance Beneficiary Notice of Noncoverage (ABN) has or has not been properly executed. Suppliers are reminded of their right to execute an ABN if the beneficiary does not meet all of the coverage criteria indicated in this policy. Claims rejected with ANSI code CO-4 are not eligible for an appeal or reopening and must be resubmitted with the appropriate diagnosis and modifier combination.

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