Medicare local coverage determination edits effective 09/01/2017

After a recent audit, it was identified that we have not been applying all Medicare local coverage determination (LCDs) edits. Effective 09/01/2017, Priority Health will begin enforcing LCD frequency edits as outlined by CMS LCD L33718.

The following CPT codes are now be subject to frequency billed edits. Durable medical equipment providers will be most impacted by this change. 

Code Description Frequency edit
Full face mask used with positive airway pressure device: each 1 per month
Face mask interface, replacement for full face mask, each 1 per month
Cushion for use on nasal mask interface, replacement only, each 2 per month
A7033 Pillow for use on nasal cannula type interface, replacement only, pair 2 per month
A7034 Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap 1 per 3 months
A7035 Headgear used with positive airway pressure device 1 per 6 months
A7038 Filter, disposable, used with positive airway pressure device 2 per month