Providers on the Hook for More CPAP Documentation

COLUMBIA, S.C. — Beginning today (April 1), sleep therapy
providers will need to adhere to more stringent documentation
requirements under a revised local coverage determination issued by
the DME MACs March 5, and they’ll need more physician notes to do
it.

According to HME consultant Andrea Stark, the PAP LCD:

• Calls for providers to have physician documentation in four
  areas before patients can be upgraded from a CPAP (E0601) to a
  bi-level (E0470);
• Changes PAP replacement guidelines; and
• Updates OSA testing devices/categories accepted by
  Medicare.

“It’s getting very strict,” acknowledged Stark of Columbia,
S.C.-based MiraVista LLC.

“The real controversial point in this LCD update is when
patients cannot tolerate or have failed a CPAP trial,” she said,
noting that rather than accepting a claim for an upgrade with only
a couple of areas of documentation, Medicare is now requiring four
elements.

The LCD states:

For beneficiaries changing from an E0601 to E0470 due to
ineffective therapy while on E0601 (either during a facility-based
titration or in the home setting), the treating physician must
document:

• The beneficiary tried but was unsuccessful with attempts to
  use the E0601 device; and
• Multiple interface options have been tried and the current
  interface is most comfortable to the beneficiary; and
• The work of exhalation with the current pressure setting of
  the E0601 prevents the beneficiary from tolerating the therapy;
  and
• Lower pressure settings of the E0601 fail to adequately
  control the symptoms of OSA or reduce the AHI/RDI to acceptable
  levels.

“The update says a physician ‘must’ — not ‘should,’” Stark
pointed out.  “That means that these things can be found as
technical errors if they are not documented.” She added that such
documentation by physicians “is not part of a routine practice.

“[Among] these four elements, maybe one or two of them are
likely to be documented … but not all of them,” Stark said.
“Now a simple notation of intolerance or that [patients] tried it
and were unsuccessful is not going to suffice [for an
upgrade].”

The new regulation could be a tripping point for providers,
especially since they have had less than a month to try to get
their physicians on board with the change.

She reminded that previous PAP LCD changes issued Jan. 22
(retroactive to Jan. 1) established a requirement for a
credentialed physician to interpret OSA results; noted coverage
requirements for patients on PAP devices prior to Nov. 1, 2008;
stated time limits/date requirements for documentation proving
medical necessity; and defined documentation of supply utilization
and shipment/deliver limitations.

Stark said that the DME MACs perhaps considered the latest
revision more of a clarification. Providers, however, look at it
differently.

“Providers see it as a very substantial shift that will require
education within the physician community,” Stark said. “It doesn’t
exactly meld with the way things are actually done.”

Several trade associations and organizations, she said, are
talking with the DME MACs to see if they will allow an extension of
the implementation deadline. But providers shouldn’t bank on a
grace period.

“Right now, this is what is written down. This is what people
need to be doing,” Stark said.

Currently, should providers be audited, they will be held to
this standard, she said, adding that sleep therapy is under
scrutiny. That fact is evidenced, she said, by the two PAP LCD
revisions issued within three months.

“They are moving toward standardization,” she said about CMS.
“We know that CPAPs are under the microscope. The changes that have
taken place in the last few years show that they are looking to do
more education and [are] pulling more claims for scrutiny.”

In other words, provider beware.

Stark will hold a Webinar on Tuesday, April 13, to discuss
revisions to the PAP LCD. For information on the Webinar, which
costs $99, go to www.miravistallc.com.