Home Blog Post


By Donna Youngblood, RN, Clinical Consultant

A joint DME MAC article was released on 05/16/19 with long awaited guidance on billing procedures after a failed 12-week PAP trial. This guidance instructs suppliers on the correct use of the KX modifier when the patient attempts a second 12-week PAP trial.

The CMS National Coverage Determination manual, IOM 1103, Chapter 1, Part 4, §240.4 limits coverage of CPAP therapy to beneficiaries who demonstrate benefit during a 12-week trial period.  The NCD §240.4 states:

The use of CPAP is covered under Medicare when used in adult patients with OSA. Coverage of CPAP is initially limited to a 12-week period to identify beneficiaries diagnosed with OSA as subsequently described who benefit from CPAP.  CPAP is subsequently covered only for those beneficiaries diagnosed with OSA who benefit from CPAP during this 12-week period.

Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea Local Coverage Determination (LCD L33718) has an option for repeating the 12-week trial following a face-to-face (F2F) clinical re-evaluation and a Type I polysomnogram (PSG).  Because of the restrictions placed by the NCD, there is no mechanism for suppliers to bill for this additional trial until the trial is complete and benefit is demonstrated.  Consequently, billing the KX modifier stops after month 3 if the initial trial fails. Suppliers may only resume billing with the KX modifier when the second 12-week trial is complete, adherence is demonstrated, and a face-to-face clinical re-evaluation has been documented.   A timeline example is provided below:

First 12-week trial

  • Suppliers can use the KX modifier during months 1-3.
  • Continued coverage after 12- week trial – suppliers may bill claims for 4th month and beyond once the F2F to assess benefit and objective evidence of adherence is met (between the 31st and 90th day).
  • If the beneficiary is seen after the 91st day but DOES have a F2F assessment and met adherence during that 31st to 91st day window, suppliers may go back (if they’re holding claims) and append the KX modifier for the 4th month and beyond.

Second 12-week trial

  • If adherence and benefit is not met during first 12-week trial, a new F2F is required to determine why adherence and benefit was not achieved AND a conduct a new PSG.  Only then does a new 12-week trial begin.
  • Suppliers may not bill the KX modifier during this new 12-week trial.
  • Only after the new 12-week trial is completed and a new F2F is conducted to assess benefit and objective evidence of adherence is met may the supplier resume billing the KX modifier (i.e., 4th claim in the 13 month capped rental cycle).

Suppliers are encouraged to read the entire Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea LCD and LCD-related Policy Articles for additional coverage, coding and coverage requirements.

Want some help? Come to the experts! 

The van Halem Group offers proactive and reactive services to assist you. Want to feel confident that the equipment you are providing meets coverage criteria? Sign up for our clinical prescreen review program.

Before you put out the equipment, let our clinical staff review your documentation to ensure the equipment meets coverage criteria. Our clinicians will review your documentation and provide you with an “approved” or “denied” status, along with recommendations for your referral source. Get your documentation right before you bill the claim to Medicare, and rest easy knowing you are protected should those claims be audited in the future.  In fact, we feel so confident in our clinical prescreen process, if you receive a denial on a claim that received vHG “approval”, we will appeal on your behalf – for free*! That is how confident we are in our  prescreen program.

*Claim must be submitted with same documentation provided at prescreen level. Any changes or alterations void free appeal.

Contact us for more information!