PAP … CPAP …

Wow! Talk about a policy changing drastically but not so frequently! The CPAP (continuous positive airway pressure) policy, now known as the PAP policy, changes Sept. 1, 2008, and you need to educate your referral sources and staff as to what your company policy is going to be to meet compliance with these changes.

Remember April 2002 when the CPAP policy changed and in July 2002 the Certificate of Medical Necessity was eliminated and the ZX (now KX) modifier was added? Well, that was easy compared to Medicare Part B’s new policy requirements. And do not think other insurers will not follow suit in pursuing these policy changes in their own policies.

Even though our patient mix of CPAP and RADs (respiratory assist devices) are not primarily Medicare patients, we still have quite a few of these as well as federal and state insurance patients who may have to meet these requirements.

First of all, a major change is that the PAP policy has become a diagnosis-driven policy. The only diagnosis that qualifies a patient for a PAP is 327.23, which is obstructive sleep apnea (adult/pediatric). A CPAP is covered for the treatment of OSA if the following conditions are met: 1) the patient has a face-to-face clinical evaluation; 2) the patient has a Medicare-covered sleep test; and 3) the patient/caregiver has received instructions on how to use the equipment.

The clinical evaluation must be performed by the “treating physician” prior to the sleep test to assess the patient for OSA. The treating physician is the physician you will go to obtain the physician progress notes required for an audit or to have the documentation to appropriately add the KX modifier. The clinical evaluation must be documented in a detailed narrative note in the physician’s chart in the format used for other entries.

For dates of service on or after Sept. 1, the clinical evaluation by the treating physician must include at a minimum: (a) sleep history and symptoms including, but not limited to, snoring, morning headaches, gasping or choking during sleep, observed apneas, excessive daytime sleepiness, and (b) Epworth sleepiness scale; and (c) physician examination that documents body mass index, neck circumference, and a focused cardiopulmonary and upper airway system evaluation.

Good luck! You know as well as I do how well the physician documents in their progress notes. It will be the provider’s responsibility to educate the physician on what documentation Medicare is requiring in progress notes for patient’s coverage.

As far as coverage guidelines, the policy added the Respiratory Disturbance Index (RDI) along with the Apnea Hypopnea Index (AHI) for coverage guidelines. Otherwise the coverage guidelines as far as numbers of episodes did not change or changed very little.

The sleep test now must be ordered by the patient’s treating physician and must be conducted by an entity that qualifies as a Medicare provider of sleep tests and is in compliance with all applicable state regulatory requirements.

For dates of service on or after Sept. 1, all patients that undergo a home sleep test must, prior to having the test, receive a face-to-face demonstration of how to apply a portable sleep monitoring device properly. This education must be provided by the entity conducting the HST and may not be performed by the DME supplier.

No aspect of an HST, including but not limited to delivery and pickup of the device, may be performed by a DME supplier. All sleep tests must also be interpreted by a physician who is either a Diplomat of the American Board of Sleep Medicine, or a Diplomat in Sleep Medicine by a member board of the American Board of Medical Specialties or an active member of a sleep center or lab accredited by the American Academy of Sleep Medicine or JCAHO. You must know this when receiving your copy of the sleep study to meet guideline policy.

Please read this full policy very carefully for all details prior to writing the new policies and procedures for your company.

Be prepared so your accounts receivable will not suffer because your intake staff has not been educated on these major changes. Educate now or pay later in an audit.

Jane Bunch is president/CEO of Jane’s Healthcare Consulting based in Marietta, Ga. A reimbursement specialist, Bunch delivers educational seminars, helps develop corporate compliance plans and serves as a consultant for fraud and abuse cases. She can be reached at 770/366-0644 or by email at [email protected].