Article Detail - JD DME
RETIRED - Billing Reminder - Maximum Allowable of PAP and RAD Accessories
Article retired due to content incorporation into the applicable Local Coverage Determination or related Policy Article.
Posted September 09, 2011
Accessories used with a PAP and/or RAD device are covered when the coverage criteria for the device are met. If the coverage criteria are not met, the accessories will be denied as not reasonable and necessary.
The following table represents the usual maximum amount of accessories expected to be reasonable and necessary:
PAP and RAD Accessories
|HCPCS Code||Usual Maximum Amounts|
|A4604||1 per 3 months|
|A7027||1 per 3 months|
|A7028||2 per 1 month|
|A7029||2 per 1 month|
|A7030||1 per 3 months|
|A7031||1 per 1 month|
|A7032||2 per 1 month|
|A7033||2 per 1 month|
|A7034||1 per 3 months|
|A7035||1 per 6 months|
|A7036||1 per 6 months|
|A7037||1 per 3 months|
|A7038||2 per 1 month|
|A7039||1 per 6 months|
|A7046||1 per 6 months|
Quantities of supplies greater than those described in the policy as the usual maximum amounts will be denied as not reasonable and necessary.
For all DMEPOS items that are provided on a recurring basis, suppliers are required to have contact with the beneficiary or caregiver/designee prior to dispensing a new supply of items. Suppliers must not deliver refills without a refill request from a beneficiary. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary.
Suppliers must not dispense a quantity of supplies exceeding a beneficiary's expected utilization.
Suppliers must stay attuned to changed or atypical utilization patterns on the part of their clients.
Suppliers must verify with the ordering physicians that any changed or atypical utilization is warranted. Regardless of utilization, a supplier must not dispense more than a three (3)-month quantity of PAP and RAD accessories at a time.
* If you are billing more than the usual maximum allowable, be sure to include information as to why the additional units are necessary. This information should be entered in the NTE 2300 or 2400 field of electronic claims or Item 19 of paper claims.
Last Updated Thu, 10 Jan 2019 13:23:12 +0000