## **What is HCPCS code E0470?**
HCPCS code E0470 represents a bi-level positive airway pressure (PAP) device, a durable medical equipment (DME) that provides independently adjustable inspiratory and expiratory pressures without a backup rate function. It’s used with a noninvasive interface, such as a nasal or facial mask, to support spontaneous breathing, especially when continuous PAP (CPAP) is ineffective or intolerable.
This device is often used for patients with respiratory insufficiency, such as those with obstructive sleep apnea (OSA), chronic obstructive pulmonary disease (COPD), or other neuromuscular diseases that affect breathing. The backup rate is a key feature, as it provides a safety net by ensuring the patient receives a breath even if they fail to initiate one on their own. Knowledge of this will ensure proper use of the medical equipment effectively.
## **Documentation requirements**
To prevent incorrect coding and ensure proper billing and reimbursement for E0470, thorough and accurate documentation is essential. Key documentation requirements include:
- **A written order** from a physician detailing the specific device (E0470) and a diagnosis that is reasonable and necessary.
- A **face-to-face clinical evaluation** by the treating physician that confirms the need for the device. The physician's notes must include:
The patient's clinical symptoms, underlying medical condition, and a summary of their medical history.
The results of a sleep study (polysomnogram) confirm the diagnosis of a qualifying condition, such as moderate to severe OSA.
A statement that the patient has failed a trial of continuous positive airway pressure (CPAP) therapy, or a documented medical reason why CPAP is not suitable.
- **The sleep study report** must be on file and show a certain level of respiratory events per hour (e.g., an Apnea-Hypopnea Index or AHI of 15 or more, or an AHI of 5-14 with documented symptoms like excessive daytime sleepiness or hypertension).
Incomplete and inaccurate documentation and the claim will be denied as not reasonable.
## **Billing requirements**
Billing for E0470 is complex and subject to strict guidelines and payment rules, particularly from the Centers for Medicare & Medicaid Services (CMS).
- **Initial billing**: The initial claim for E0470 is for a rental period, typically a monthly fee.
- **Proof of continued need**: After the initial rental period (usually 3 months), providers must submit documentation proving the patient continues to use the device. This is often done by downloading data from the device showing compliance. CMS requires at least 4 hours of use per night on 70% of the nights during the initial 30-day period.
- **Purchase option**: After a certain number of rental months (often 13 months for Medicare), the device may be purchased by the patient from the supplier.
- **Modifiers**: Specific modifiers are often used with E0470 to indicate the type of rental or purchase. For example, a "K-" modifier may be used to indicate a rental period.
Do note that a new face-to-face evaluation and written order is required only if a patient switches from CPAP (E0601) after more than three months of use—no new sleep study is needed.
## **Other relevant codes**
- **E0601**: Continuous positive airway pressure device
- **E0471**: Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface
- **E0467**: Home ventilator, multi-function respiratory device, also performs any or all of the additional functions of oxygen concentration, drug nebulization, aspiration, and cough stimulation, includes all accessories, components, and supplies for all functions
Frequently asked questions
