More RAD Requests

As the sleep community becomes more aware of the incidence of complex sleep apnea, HME providers are seeing more requests to distribute the E0471 “respiratory assist device with back up rate.” While that can be good news for those who are trying to enhance their respiratory product offering, it is not good news if the medical records are not adequately detailed. The same is true for a diagnosis of central sleep apnea.

When considering only patients who are new to therapy (not upgrading from CPAP), there are some very specific requirements that must be met in order for you to get paid and keep your money.

It all starts with the diagnosis. There are a limited number of diagnoses that, per the LCD, demonstrate the need for an E0471. Every one of them must also be validated by diagnostic testing results that are mandated. The addition of the KX modifier on the claim indicates the supplier has validated that all the required metrics have been met and are contained within the medical record.

Note that obstructive sleep apnea (OSA) is not one of them. Think of the E0471 as a device that actually helps someone breathe when, due to disease, they are not able to do so well enough on their own. This is opposed to CPAP, which is utilized to keep the airway splinted open, not actually assist with the mechanics of breathing.

There are only four disease types that are articulated within the LCD as impairing a person's breathing, thus warranting the dispensing of an E0471:

1. Restrictive Thoracic Disorder

   Imagine a person who simply cannot take a deep breath due to disease or deformity. Severe kyphoscolisos or other chest wall deformities fit here. This category at times will function as a catch-all, as it will often include patients who have neuromuscular/neurological diseases such as ALS, MS or muscular dystrophy.

2. COPD

   These patients usually can get the air in fine, but due to degeneration of the lung, cannot get the air out. This causes a buildup of carbon dioxide, thus the need for assistance in getting rid of the old air. Think of the old adage “In with the good air, out with the bad.” Measurement of “PCO2” (the pressure of the carbon dioxide gas in the blood, which, if high, indicates poor breathing) is one of the required diagnostic tests.

3. Central Sleep Apnea or Complex Sleep Apnea

   Simplistically stated, central apneas are not a lung or airway problem. Instead, think of the brain just not sending the signal to the lung to breathe. In this case, the patient needs assistance in breathing.