Does A4575 require prior authorization?

No, A4575 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for A4575?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`A4575`, Topical hyperbaric oxygen chamber, disposable

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

When billing for denial of related physician services on a Part B claim, enter '99199-related to Topical HBO' in the comment/narrative field (Loop 2400 or SV101-7 for the 5010A1 837P Item 19 and in Item 19 for paper claims).
Reference CMS guidance: Change Request 10220, Transmittal 203, Transmittal 3921, and Internet-Only Manual Pub 100-04 Claims Processing Manual Chapter 32 Section 30.2 for policy authority and specific procedural/billing instructions.

This article provides billing and coding guidance that complements LCD L37873; any required medical documentation, prior authorizations, or specific claim forms are detailed in L37873 and should be referenced for claims submission.

A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; for DMEPOS base items requiring a Written Order Prior to Delivery (WOPD), the supplier must receive a signed WOPD before delivery or the claim will be denied.

Proof of delivery (POD) documentation must be maintained by the supplier and made available to the Medicare contractor on request; claims without appropriate POD will be denied.

Qualifying blood gas studies must comply with MAC policy standards and be performed by a provider qualified to bill Medicare (Part A provider, laboratory, IDTF, or treating practitioner); suppliers may not perform or pay for qualifying blood gas testing.

Key Coverage Criteria

Topical oxygen therapy for chronic wounds is not covered by a National Coverage Determination; coverage determination is made by the local Medicare Administrative Contractor (MAC).
This billing and coding article does not itself define clinical indications; follow the Topical Oxygen Therapy Local Coverage Determination L37873 for covered clinical indications for topical oxygen therapy.
Initial coverage for home oxygen and oxygen equipment is reasonable and necessary only if the treating practitioner ordered and evaluated a qualifying blood gas study performed at the time of need, the study meets the coverage criteria, the study was performed by a treating practitioner or qualified provider/laboratory, and provision of home oxygen is expected to improve the beneficiary’s condition.
Group I: Coverage if arterial PO2 ≤ 55 mm Hg or arterial oxygen saturation ≤ 88% at rest (awake) breathing room air.
Group I (sleep-only): Coverage if arterial PO2 ≤ 55 mm Hg or arterial oxygen saturation ≤ 88% during sleep for a beneficiary who demonstrates PO2 ≥ 56 mm Hg or saturation ≥ 89% while awake, with oxygen reasonable and necessary only during sleep.
Group I (sleep desaturation from baseline): Coverage if during sleep PO2 decreases >10 mm Hg or oxygen saturation decreases >5% from baseline and the decrease is associated with hypoxemia symptoms (e.g., cognitive impairment, nocturnal restlessness), with oxygen reasonable and necessary only during sleep.

20 Active Policies

PALMETTO-JJ-L37873, Topical Oxygen Therapy

PALMETTO-JM-L37873, Topical Oxygen Therapy

A56431, Billing and Coding: Topical Oxygen Therapy

L33797, Oxygen and Oxygen Equipment

UHC-POL-hyperbaric-topical-oxygen-therapy, Hyperbaric Oxygen Therapy and Topical Oxygen Therapy

AETNA-CPB-0788, Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments

AETNA-CPB-0172, Hyperbaric Oxygen Therapy (HBOT)

AETNA-CPB-0327, Infertility

AETNA-CPB-0648, Autism Spectrum Disorders

AETNA-CPB-0244, Skin and Soft Tissue Substitutes

CIGNA-0053, Hyperbaric and Topical Oxygen Therapies

BCBSIL-THE801.003, Hyperbaric Oxygen (HBO2) Therapy

BCBSMT-THE801.003, Hyperbaric Oxygen (HBO2) Therapy

BCBSNM-THE801.003, Hyperbaric Oxygen (HBO2) Therapy

BCBSOK-THE801.003, Hyperbaric Oxygen (HBO2) Therapy

REGENCE-MED14, Hyperbaric Oxygen Therapy

UMR-POL-UMR-hyperbaric-topical-oxygen-therapy, Hyperbaric Oxygen Therapy and Topical Oxygen Therapy

ANTHEM-CG-MED-73, Hyperbaric Oxygen Therapy (Systemic/Topical)

SUREST-POL-SUREST-hyperbaric-topical-oxygen-therapy, Hyperbaric Oxygen Therapy and Topical Oxygen Therapy

A56025, Billing and Coding: Topical HBO and Physician Related Service Billing and Coding Guidelines

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A4575, Topical hyperbaric oxygen chamber, disposable