Policy Refresher: Billing for Obstructive Sleep Apnea Under Medicaid Home Oxygen Therapy Services

Clinical Medical Policy Name: Home Oxygen Therapy (HOT)

Policy Number: MP-069-MD-PA

Original Effective Date: 12/01/2017

Products: Highmark Wholecare℠ Medicaid

Policy Statement

Highmark Wholecare℠ may provide coverage under the Durable Medical Equipment (DME) benefits of our Medicaid products for medically necessary oxygen therapy in the home. This policy addresses documentation and clinical requirements necessary for use of oxygen gas cylinders, liquid oxygen, and oxygen concentrators.

This policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person’s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records.

Diagnosis Requirements – Coding for Obstructive Sleep Apnea

ICD-10 code G47.33 is used for diagnosing and billing Obstructive Sleep Apnea (OSA) in both adults and pediatric patients, excluding newborns. To code for OSA, an underlying cardiopulmonary condition must be coded in combination (for example, Obstructive Sleep Apnea with chronic lung disease or pulmonary hypertension). Due to the volume of diagnosis codes, please reference this policy for the list of cardiopulmonary conditions that are considered medically necessary.

In order to prevent claims from being rejected unnecessarily, please be sure to refer to these policy guidelines and resources when billing Medicaid Home Oxygen Therapy Services.  Highmark Wholecare monitors claims billing and payments to comply with federal and state requirements. Identified overpayments are required to be refunded to Highmark Wholecare. As a reminder, CMS requires providers to perform Self-Audits when issues are identified as well as on an on-going basis to ensure compliance.

Disclaimer

Highmark Wholecare℠ medical policy is intended to serve only as a general reference resource regarding coverage for the services described. This policy does not constitute medical advice and is not intended to govern or otherwise influence medical decisions.

Resources:

• Full Policy
• 2025 ICD-10-CM Diagnosis Code G47.33