Understanding Medicare Billing for Mask Interfaces: A Crucial Advisory from ACU-Serve
At ACU-Serve, we are committed to providing accurate and compliant billing services for those we serve. Recently, an issue has come to our attention regarding the billing of Medicare for the mask interface (pillow or cushion) that comes packaged with the mask.
After careful review, ACU-Serve believes that suppliers should not bill Medicare separately for the mask interface included with the mask. Here are the reasons behind our stance:
Replacement Only: Clarifying Billing Guidelines
The description for mask pillows and cushions includes the statement “replacement only.” This implies that when these items are billed, they are intended to replace an existing cushion or pillow in use. The mask is considered complete with the appropriate interface (pillow or cushion) upon initial issue. A parallel can be drawn to the billing practices for humidifiers and water chambers. The water chamber is included with the initial humidifier and is not separately billable when initially issued. Billing the water chamber separately upon initial issue is considered unbundling. Similarly, billing the mask and the cushion or pillow that comes with it separately may also be considered unbundling.
Precedent with Medicare: Billing Free Items
There is a long-standing precedent with Medicare that providers should not bill Medicare for items they receive for free. According to the CMS Article on Billing and Coding for Patients Supplied Donated or Free-of-Charge Drugs (A55044), providers can only bill Medicare for drugs that are purchased by the physician, from the pharmacy, and administered in the physician’s office. While this guidance is specifically for drugs, the principle remains applicable. The OIG has published guidance stating that it is legal to give free samples to patients but illegal to sell them or bill Medicare for them. Upon reviewing several suppliers’ invoices, we did not find an itemized charge for the cushions or pillows included in the mask package. There was only one charge for the mask, reinforcing our belief that it is inappropriate to bill Medicare separately for the cushion or pillow included with the mask.
Manufacturer Guidelines: Complete Packages
Manufacturers consider the package containing the mask and the pillow/cushion as complete, which should not be separately billed. For example, ResMed has clarified that their mask systems and headgear are complete accessories, which include the cushion or pillows. Their factsheet states that the frame system for each mask type includes all necessary components, underscoring the completeness of the package .
Compliance and Best Practices
At ACU-Serve, we prioritize compliance and ethical billing practices. Our goal is to ensure that our clients navigate the complexities of Medicare billing with integrity and transparency. While Medicare may not currently have an edit to deny these claims, this practice may run afoul of Medicare guidelines for the enumerated reasons above. ACU-Serve strongly recommends suppliers discontinue the practice and evaluate whether or not prior claims should be reviewed for potential refunds. ACU-Serve will not knowingly bill or attempt to collect for the pillow or cushion included in the packaging for the mask.
If you have any questions or need further clarification on this matter, we look forward to connecting with you!
Sources:
- CMS Article – Billing and Coding: Patients Supplied Donated or Free-of-Charge Drug (A55044)
- OIG Guidance on Free Samples and Billing
- ResMed Reimbursement Factsheet