HCPCS A7035: Headgear used with positive airway pressure device

Learn how to properly use and bill for HCPCS code A7035 with our short guide.

## **What is HCPCS code A7035?** HCPCS Code A7035 is a Level II code under the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) benefit, maintained by the Centers for Medicare & Medicaid Services (CMS). It describes the headgear used with positive airway pressure (PAP) devices, such as continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP) machines, which are prescribed to treat obstructive sleep apnea (OSA) and related respiratory conditions. The A7035 headgear keeps the PAP mask or interface securely in place, helping maintain a consistent seal for effective air pressure delivery during sleep. Most headgear is made of soft, elastic materials to balance comfort and stability. Over time, it can stretch or wear down, so replacements are considered medically necessary to maintain therapy effectiveness and hygiene. When billing A7035, suppliers must comply with Medicare DMEPOS coverage criteria under the Social Security Act. Before issuing replacement accessories, the supplier must confirm whether same or similar equipment has already been provided to the beneficiary. If the PAP device is beneficiary-owned equipment identified under a previous claim, documentation must show continued medical necessity and use. A documented refill request is required before dispensing replacement headgear. Suppliers must contact the beneficiary to verify that the item remains needed and that the previous supply is nearly exhausted. Failure to document these steps may result in claim denials. The A7035 code only applies to PAP accessories, not to oral appliances, oxygen equipment, or multi-function respiratory devices such as ventilators. Those fall under different HCPCS categories and coverage guidelines. Replacement frequency for A7035 headgear is typically one unit every six months when medically necessary and supported by documentation in the patient’s medical record. Proper coding and verification ensure compliance with CMS rules and reduce the risk of overlapping reimbursement for same or similar equipment.

## **Documentation requirements** Coverage and payment for PAP device accessories, including headgear, are subject to meeting specific criteria, often detailed in payer policies like Medicare's Local Coverage Determinations (LCDs) and Policy Articles. The documentation must support the initial medical necessity of the base PAP device (like a CPAP machine, E0601) and the ongoing need for replacement supplies. Key documentation requirements generally include: - **Written order/prescription**: A valid prescription from the treating practitioner for the base PAP device and the corresponding accessories. - **Medical Necessity for the base device**: Documentation confirming the patient meets the coverage criteria for the PAP device (e.g., diagnosis of OSA confirmed by a sleep study with specific Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) thresholds). - **Continued medical need**: For replacement supplies like A7035, the patient's medical record must document that the patient continues to use the PAP device and that the base PAP equipment (E0601, E0470, etc.) remains medically necessary. - **Refill documentation**: For all replacement supplies, the supplier must have a dated refill record that includes an affirmative response from the patient or caregiver indicating a need for the refill, a description of each item being requested, and contact must be made with the patient prior to dispensing the new supply.

## **Billing and coverage** Billing for HCPCS code A7035 is governed by payment rules or guidelines from the payer (e.g., Medicare, private insurance). Here are some of them: - **Replacement frequency**: The headgear (A7035) is typically eligible for replacement one (1) time every six (6) months of continuous use. Billing for a greater quantity or earlier than the replacement schedule is usually denied. - **Modifiers**: Appended modifiers like the following are appended depending on the circumstance: KX Modifier (This modifier is often required on the claim line for A7035 to attest that the supplier has documentation that all of the coverage and medical necessity requirements have been met) and the EY Modifier (Used to indicate that there is no physician or other licensed healthcare provider order for the item or service, which often results in a non-covered denial). - **Base equipment**: Coverage for A7035 depends on the base PAP or respiratory assist device (RAD) being active and medically necessary. The primary device, such as a CPAP (E0601), BiPAP (E0470/E0471), or other RAD, must have been previously covered and paid for by the payer, or the beneficiary must now own the equipment following the rental period. Accessories like headgear are only covered if they are essential for the continued use of this base equipment.

## **Related HCPCS codes** - **E0601**: Continuous positive airway pressure (CPAP) device (Base Equipment) - **A7034**: Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap - **A7030**: Full face mask used with positive airway pressure device, each - **A7031**: Face mask interface, replacement for full face mask (cushion), each - **A7032**: Cushion for use on nasal mask interface, replacement only, each - **A7033**: Pillow for use on nasal cannula type interface, replacement only, pair - **A7036**: Chinstrap used with positive airway pressure device - **A7037**: Tubing used with positive airway pressure device - **A7038**: Filter, disposable, used with positive airway pressure device

Frequently asked questions

A7035 is only for the headgear (the straps that secure the mask). The mask itself (the interface) has its own separate code (e.g., A7030 for a full face mask, A7034 for a nasal mask).

Billing more frequently than the established replacement schedule (typically 1 per 6 months for A7035 under Medicare) will likely result in a denial, as the item would be considered not medically necessary or exceeding the quantity limits.

No. Replacement accessories like A7035 are only covered if the base PAP equipment continues to meet the medical necessity requirements and the patient is compliant with and actively using the device. Compliance is generally checked using objective data (e.g., machine download).