Medicare Rules for Mask Replacement ??

I am using a Resmed Swift LT mask. According to Medicare rules, the mask can be replaced every 3 months. HCPCS code A7034 is used and according to Medicare is for "Nasal Interface (Mask or Cannula type) used with positive airway pressure device, with or without head strap. This suggests to me that the entire mask, including headgear, can be replaced every 3 months. However, HCPCS code A7035 is for the headgear and is allowed only every 6 months.

My DME supplier bills Medicare for both A7034 and A7035 when they supply the mask with headgear. They argue that they don't get paid for the headgear unless they bill it this way.

I would like a complete mask and headgear replacement every 3 months. It seems to me that code A7034 covers the entire replacement and is allowed every 3 months. Code A7035 might be there for those who want an extra headgear ?? My DME says I'm wrong and code A7034 covers the mask only with no headgear and that's what they send me.

Has anyone else had this experience? Does your DME provider bill for the mask and headgear separately, even though they come in the same package? Do you get a complete replacement every 3 months?

JIMCHI wrote:Has anyone else had this experience? Does your DME provider bill for the mask and headgear separately, even though they come in the same package? Do you get a complete replacement every 3 months?

My insurance is based on what Medicare allows.
It is common for all DMEs to bill separately for head gear and mask even though they are in same package. Medicare pays this way. So do most other insurance companies. It is quite legal.

Now that 3 month allowance for a new mask is really quite misleading. I have questioned it myself because common sense says it would include new head gear. Well, sometimes Medicare doesn't use common sense. It does not include head gear. It seems like a new mask only might be obtained as long as it is to be used with existing head gear. Problem being many DMEs don't supply mask replacement parts. Much of the time they only stock the complete mask which includes the head gear. They could stock replacement parts or order them but much of the time they don't want the extra paperwork or simply don't have the room to stock replacement parts..

Bottom line is that while Medicare allows for new mask (minus head gear) at the 3 month mark the DME may or may not have that particular part available minus the head gear. If someone is wanting to try a completely new mask then they have to wait 6 months to have Medicare cover it because of the head gear thing. So your DME is doing what is allowed. We don't get head gear every 3 months.

I would like a complete mask and headgear replacement every 3 months. It seems to me that code A7034 covers the entire replacement and is allowed every 3 months. Code A7035 might be there for those who want an extra headgear ?? My DME says I'm wrong and code A7034 covers the mask only with no headgear and that's what they send me.



Because Medicare "allows" does not relate to "need". Masks don't usually wear out in 3 months. I have been using my Quattro for over a year . I have replaced the headgear once and the silicone insert 4 times (medicare allows 1 in 30 days). IN MY OPINION...asking for replacements according to the Medicare schedule, just because it is allowed, is a misuse. This is one many reasons Medicare is in trouble.

When first going on CPAP you may want to get a second mask as a back up after 3 months.......That's an exception.

I actually need the headgear more frequently. It just does not seem to hold properly and needs constant adjustment after 3-4 months.

I do want clarification as to what the Medicare rules are- as far as I can see they say complete mask replacement every 3 months is OK. I called Medicare and the agent said "that's what the code A9034 says". Just want to know what others are experiencing with their DME providers. Pugsy seems to agree with my DME provider, so that may be the answer - that the rule doesn't make any sense. My DME does carry the headgear separately, but would charge me if I want it more than every 6 months.

The Swift LT is not as durable as the Quattro as the Quattro has mostly rigid parts while the Swift LT is mostly soft parts.

JIMCHI wrote:as far as I can see they say complete mask replacement every 3 months is OK

I haven't seen anything saying the word "complete". I have only seen CPAP Mask A7034 and Headgear as A7035. Pretty much the norm for them to be billed separately.

If you can't get the DME to do what you want and you feel your head gear just has to be replaced there is always Ebay.
I have seen the head gear sell for as little as $10. Much, much less than online replacement costs.

I use the Swift FX and I have no problems with head gear lasting way longer than the 6 months but then I routinely get many months of use out of the nasal pillow. Latest has not needed any adjustment since I got it in Dec of last year.

I agree that A0734 should mean mask AND headgear, as long as the DME codes it properly. DME's make more money coding them separately, but at that 3 month interval there is no coverage for SEPARATE headgear. You may try calling around to other local DME's to see what they say--just because your machine is rented from one DME does not obligate you to get your supplies from them.

If necessary, buy your own headgear from the internet and just get the mask. If your DME is too lazy to do the ordering and billing for a mask alone, make a complaint to your insurer and their company. THAT's what they are in business for.

While I agree with LSAT that you don't have to replace supplies as often as Medicare ALLOWS, it makes sense to have some backup items on hand in case something breaks, gets damaged or lost. AND, there's limited opportunity to try a new mask if you're not that happy with the one you have.

HCPCS code A7034 is used and according to Medicare is for "Nasal Interface (Mask or Cannula type) used with positive airway pressure device, with or without head strap.

The code is poorly written, and can be interpreted two ways.

1. The way you are interpreting it is that the code can include the interface as well as the headgear, or, if one chooses, it can just include the interface. In this interpretation, you are looking at the "with or without" as referring to what may be included under that code.

2. The other way to interpret the statement is that the "with or without" is modifying not what is included in the code, but the definition of "nasal interface." In this interpretation, only the nasal interface is included in the code, not the headgear. The phrase "with or without head strap" simply states that the nasal interface may or may not also require a head strap. Just because the nasal interface requires a head strap, it does not necessarily mean it's covered under this code.

I have a feeling that the second definition might be correct, and that the reason the "with or without head strap" modifier came about was probably this mask or something similar: https://www.cpap.com/productpage/CPAP-P ... -mask.html

I do want clarification as to what the Medicare rules are- as far as I can see they say complete mask replacement every 3 months is OK. I called Medicare and the agent said "that's what the code A9034 says".

Did the agent say that your interpretation was correct, or did she just confirm for you that the wording of the code that you have is correct? Big difference there.

I asked the Medicare agent if that meant I could get another mask and headgear every 3 months and she said "yes". But she may have just used the same logic that I used.

What if you were switching masks and your current headgear wouldn't work?????? Challenge the DME with that question and see what they answer.

Isn't there a medicare fraud hotline?

My DME works it this way for the three month replacements:

If I get a replacement mask, of a mask I already have, all I can get is the mask itself, no headgear.

If I get a replacement mask that I've never had before, I get both mask & headgear.

NOW.....getting a new mask & headgear setup, doesn't effect the 6 month replacement of the headgear alone. If I ordered a new style mask today, I could still order a replacement headgear (if it's been 6 months from the last time) for an old mask.

I think I have read here that some DME's will include the entire mask for the patient esp. if/when the parts aren't available separately. Mine does NOT do that as there is no "just headgear" for the Aeiomed Headrest that I am aware of. Maybe trying another DME will help.

Sometimes you can take the headgear off one model and use it on another. Reading RestedGal's threads on making your own straps got me using knee high pantyhose to help seal my masks. @ 3pr/$1 can't beat that.

The DME that I work for sends an entire mask/headgear setup every three months, if needed. We only bill for the headgear every six months though. So basically the patient gets a new headgear every three, but is only charged every six. It is too much trouble to keep separate headgears for each mask style. We do stock some of the large headgears for ones that require it. When we order from the manufacturer, we get a lower price if we buy it as a complete setup, instead of buying mask & headgear separate.
I'm actually surprised other DMEs don't do it this way.

Sorry that I've not registered as an user yet. I discovered your forum a month or two ago. It has given me insight in what cpap users go though, and tips to pass on to my clients.

Guest wrote: Sorry that I've not registered as an user yet. I discovered your forum a month or two ago. It has given me insight in what cpap users go though, and tips to pass on to my clients.

Welcome to our site. Please register when you get the chance. It only takes a minute.

Guest wrote:The DME that I work for sends an entire mask/headgear setup every three months, if needed. We only bill for the headgear every six months though. So basically the patient gets a new headgear every three, but is only charged every six. It is too much trouble to keep separate headgears for each mask style.
Sorry that I've not registered as an user yet. I discovered your forum a month or two ago. It has given me insight in what cpap users go though, and tips to pass on to my clients.

Welcome Guest, please register and we'd like your insight also. That's the way our DME does it too. I may be wrong but I think all masks come sealed with headgear included and I don't think I'd accept a package that was unsealed and the headgear removed.