HCPCS A7028: Oral Cushion for Combination Oral/Nasal Mask, Replacement Only - OpenPayer

Summary & Overview

HCPCS A7028: Oral Cushion for Combination Oral/Nasal Mask, Replacement Only

HCPCS Level II code A7028 denotes an oral cushion component for a combination oral/nasal mask, sold as a replacement part. This code matters nationally because replacement components are essential to maintaining effective noninvasive positive airway therapy, supporting patient adherence and device performance. Accurate coding for replacement parts affects coverage determinations, claims processing, and out-of-pocket costs for patients.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the clinical context and service setting, guidance on typical claims considerations, and benchmarking topics relevant to payer coverage policies and reimbursement for replacement respiratory device components. The publication outlines common billing practices, expected sites of service, and areas where payers commonly provide explicit coverage language for replacement items. Data not available in the input is noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareA7028HCPCS Level IIoral cushionrespiratory devicereplacement partdurable medical equipmentnoninvasive ventilationmask interfacehome respiratory care

Billing Code Overview

HCPCS Level II code A7028 describes an oral cushion for a combination oral/nasal mask, replacement only, each. This item is a replacement component for respiratory interface systems that combine oral and nasal seal features to support positive airway therapy.

Service type: Replacement respiratory device component
Typical site of service: Durable medical equipment settings, home use, and outpatient clinics where patients receive noninvasive positive airway therapy

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A patient with obstructive sleep apnea (OSA) or another sleep-related breathing disorder uses a combination oral/nasal continuous positive airway pressure (CPAP) mask. During routine equipment maintenance or when the oral cushion shows wear, the durable medical equipment supplier or respiratory therapist provides a replacement oral cushion component described by HCPCS Level II code A7028 (oral cushion for combination oral/nasal mask, replacement only, each). Typical workflow: the sleep clinician documents mask fit issues or patient complaints (air leak, skin irritation, cushion degradation) during a follow-up visit; an order for a replacement cushion is placed by the clinician or durable medical equipment supplier; the supplier dispenses the replacement cushion and bills payors using A7028. Typical site of service: durable medical equipment supplier, sleep clinic, outpatient respiratory therapy clinic, or patient home delivery. A realistic patient scenario: a 58-year-old patient with moderate OSA reports increasing air leakage around the mouth interface at a 3-month follow-up; the sleep technologist confirms visible cushion breakdown and documents the need for a replacement oral cushion; the supplier dispenses one replacement cushion and bills A7028 for that item.

Coding Specifications

Modifier	Description	When to Use
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Related Codes

HCPCS-LEVEL-II-A4404-OSTOMY-RING

HCPCS Level II A4404: Ostomy Ring, Each

HCPCS-A4629-TRACHEOSTOMY-CARE-KIT-ESTABLISHED-TRACHEOSTOMY

HCPCS Level II A4629: Tracheostomy Care Kit for Established Tracheostomy

HCPCS-A4414-OSTOMY-SKIN-BARRIER-FLANGED-4X4-OR-SMALLER

HCPCS A4414: Ostomy Skin Barrier with Flange, ≤4 x 4 Inches

HCPCS-A6601-GRADIENT-COMPRESSION-FOAM-PAD

HCPCS Level II A6601: Gradient Compression Foam Pad

HCPCS-A4611-HEAVY-DUTY-VENTILATOR-BATTERY-REPLACEMENT

HCPCS A4611: Heavy-Duty Battery Replacement for Patient Ventilator

HCPCS-A6589-GRADIENT-PRESSURE-WRAP-BRA

HCPCS A6589: Gradient Pressure Wrap with Adjustable Straps, Bra

HCPCS-A7520-TRACHEOSTOMY-TUBE-NON-CUFFED-PVC-SILICONE

HCPCS A7520: Tracheostomy/Laryngectomy Tube, Non-Cuffed

HCPCS-A5072-URINARY-OSTOMY-POUCH-ONE-PIECE-NO-BARRIER

HCPCS Level II A5072: Urinary Ostomy Pouch, One-Piece Without Barrier

HCPCS-A6540-GRADIENT-COMPRESSION-STOCKIN-WAIST-LENGTH-30-40-MMHG

HCPCS Level II A6540: Waist-Length Gradient Compression Stocking, 30-40 mmHg

HCPCS-A6609-GRADIENT-COMPRESSION-BANDAGING-SUPPLY

HCPCS A6609: Gradient Compression Bandaging Supply, Not Otherwise Specified

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Taxonomy Code	Specialty	Notes
`Respiratory Therapist`	Respiratory Therapy	Common provider involved in mask fitting, cushion replacement, and patient education.
`234U00000X`	Sleep Medicine Physician	Specialist who manages OSA therapy and orders DME supplies.
`207RH0000X`	Otolaryngology (ENT)	May assess airway anatomy affecting mask fit and recommend specific interfaces.
`363A00000X`	Durable Medical Equipment Supplier	Entity that dispenses and bills for `A7028`.
`2080P0207X`	Internal Medicine	Primary care physicians who manage chronic OSA patients and authorize replacements.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`G47.33`	Obstructive sleep apnea (adult) (pediatric)	Primary diagnosis driving chronic use of CPAP/BiPAP devices that utilize combination oral/nasal masks requiring replacement cushions.
`G47.30`	Sleep apnea, unspecified	Used when sleep apnea is documented but specific type is not recorded; still supports need for CPAP interface supplies.
`J96.00`	Acute respiratory failure, unspecified whether with hypoxia or hypercapnia	Patients recovering from respiratory failure may use noninvasive ventilation interfaces that include oral cushions.
`J44.9`	Chronic obstructive pulmonary disease, unspecified	COPD patients using noninvasive ventilation interfaces may require oral/nasal mask cushions as part of therapy.
`R06.81`	Nasal congestion	Contributes to interface selection and may lead to greater reliance on oral cushion contact or combination masks.
`Z99.11`	Dependence on respirator [ventilator] (ventilator dependence)	Long-term noninvasive ventilation users require ongoing maintenance and replacement of mask components.
`Z46.89`	Encounter for other specified procedures for devices, implants and grafts	Administrative code used for encounters centered on device maintenance, including cushion replacement.
`T85.39XA`	Other mechanical complication of other specified internal prosthetic device, implant and graft, initial encounter	Used if a device interface has failed or caused complications necessitating component replacement.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`94660`	Continuous positive airway pressure ventilation (CPAP), initiation and management	May be performed during initial CPAP setup visits where mask interface selection and cushion fitting occur prior to dispensing a replacement `A7028` cushion.
`95810`	Polysomnography, sleep staging with continuous recording of EEG, etc.	Diagnostic sleep study that establishes the need for CPAP therapy; results inform ongoing equipment adjustments and replacement needs.
`94664`	Bi-level ventilation via noninvasive interface (e.g., BiPAP), initiation and management	Applicable when a patient uses combination oral/nasal masks with bilevel devices and requires interface replacement.
`99070`	Supplies and materials (e.g., DME) provided by the physician over and above those usually included	Used in clinical settings when supplies like a replacement cushion are furnished directly by a clinic and billed to payors alongside clinical services.
`99213`	Office or other outpatient visit for the evaluation and management of an established patient	Common visit code for follow-up where mask fit issues are evaluated and a replacement cushion (`A7028`) is ordered.