Wake Up to Billing for Sleep Apnea

In 2002, the DMERCs changed coverage policies for CPAPs and supplies to treat those diagnosed with obstructive sleep apnea (OSA). These changes opened the doors to many who could not receive treatment under the old policy.

Now, continuous positive airway pressure devices (CPAPs) — HCPCS code E0601 — are covered for patients diagnosed with OSA documented by a facility-based, attended polysomnogram (sleep study) and who meet either of the following criteria: (1) The apnea hypopnea index (AHI) is greater than or equal to 15 events per hour, or (2) The AHI is from five to 14 events per hour with documented symptoms of (a) hypertension, history of stroke or ischemia heart disease; or (b) excessive daytime sleepiness, impaired cognition, mood disorders or insomnia.

Correct Documentation

You must have documentation in the patient’s medical files of all symptoms for those patients who have an AHI between five and 14 events. In filing claims, both the CPAP and supplies require a “KX” modifier. Highly audited, the KX modifier states to the DMERC that you have met all criteria set forth by the policy.

But do not depend on physicians to have all required information in their patient files. The physician will not be the responsible party reimbursing Medicare back if the correct documentation is not retrieved in an audit.

To verify the number of events documented at intake and on the physician order, you must obtain a copy of the polysomnogram. Do not continue to use the certificate of medical necessity (CMN), which asks questions regarding only apnea episodes per the old policy, not the AHI.

Verify that the sleep study was performed in a facility-based sleep study laboratory and not in the home or in a mobile facility. The lab must be qualified by Medicare to provide these services and must comply with all applicable state regulatory requirements.

The DME supplier may not perform the polysomnogram. Of course, this prohibition does not extend to hospitals certified to perform such tests.

The physician order must document the CPAP description, itemize all accessories, contain the medical necessity as warranted by the policy, the diagnosis, the length of need, any documented additional information required, the treating physician’s information and the patient’s name and health insurance carrier (HIC) number. Also keep a copy of the polysomnogram in the patient’s medical file.

Note that when CPAPs are covered under the policy, OSA accessories are covered separately. The CPAP is a capped rental item while supplies are sole items. If a patient requires additional supplies than Medicare’s usual allowance, additional medical documentation must be submitted.

Proper Follow-Up

Because patient compliance and proper equipment use is so important for OSA patients, follow-up is vital. As part of the coverage criteria, you must contact patients between 61 and 90 days after the initial date of service to verify they are using the equipment and that it is beneficial for the treatment of their diagnosis.

You may verify continued use from the physician or the patient per the policy. This may be accomplished with a letter to be returned to you or with a telephone call log documenting the call and results of the call. You may not continue to bill the fourth month with a KX modifier without verifying this information.

If patients say they are not using the equipment, it is the provider’s responsibility to stop billing and pick up the equipment.

With today’s Medicare coverage policy and skyrocketing diagnoses of OSA, waking up to the business of sleep apnea may make sense for your company. And with proper documentation and follow-up to ensure compliance, both you and your patients should sleep very well.

Jane Bunch is president of DMEs of America, a Miami-based holding company, and CEO of Kennesaw, Ga.-based JB&CS, a division of DMEA. A reimbursement specialist, Bunch delivers educational seminars worldwide, helps develop corporate compliance plans and serves as a consultant for fraud and abuse cases. She can be reached at 678/445-1221 or via e-mail at [email protected].