New DME Edit for HCPCS code E0483

HCPCS code E0483 is an airway clearance device known under the brand name The Vest® System and is a covered benefit under Clinical Policy 5A - Durable Medical Equipment and Supplies (5.3.18 High Frequency Chest Wall Oscillation Device). According to the Clinical Policy for E0483, the "Lifetime Expectancy or Quantity Limitation" is listed as Lifetime. The device requires Prior Authorization. Once prior authorization has been granted, claims billed with E0483 are processed and paid based on either a rental price or purchase price.

HCPCS codes A7025 and A7026 are related to E0483 and represent replacement parts for the patient owned equipment. A7025 is the replacement vest and A7026 is for hose replacement. Both of these items are also limited to once per lifetime.

On February 1, 2016, new edits will be implemented in NCTracks to rectify a situation that has allowed for overpayments to occur. The edits will prevent accumulated payments for HCPCS codes E0483, A7025 and A7026 from exceeding the maximum allowed purchase price of the equipment. The claim that causes the purchase price to be exceeded will have pricing cutback applied and cutback payment to equal the maximum allowed purchase price. A pay and report edit 57779 - PAYMENT CUTBACK TO MAXIMUM ALLOWED AMOUNT will be set when the maximum allowable has not been met and some amount of payment is allowed. Once the maximum allowed purchase price has been met, all subsequent claims for the item will be denied with Edit 57770 - ITEM ALLOWED ONLY ONCE IN LIFETIME.

A reprocessing of DME claims is planned to recover the overpayments. More information will be forthcoming regarding the timing of the claim reprocessing.