DME MACs Issue ‘Kinder’ Sleep LCD

ATLANTA–Weeks after tabling the Sept. 1 implementation date for
the local coverage determination for PAP devices, the DME MACs last
week issued a revised LCD that eased at least some of the
restrictions included in their first version of the medical
policy.

The newly revised LCD was greeted with measured enthusiasm from
industry stakeholders who noted, among other things, that it
revises coverage criteria for documentation of the initial
evaluation and also the requirement for beneficiary education by
the entity conducting a home sleep test.

It also extends the implementation dates for credentialing of
physicians interpreting the HSTs and facility-based polysomnograms
and expands the dates during which patients must be re-evaluated
for documenting benefits from PAP therapy.

“It’s a much softer, kinder version,” said
Kelly Riley, director of the National Respiratory Network for The
MED Group, Lubbock, Texas. “Home sleep testing is back
in.”

But HME providers hoping for the green light to perform HSTs
were disappointed.

“It does not open the door for providers to do [home]
sleep testing,” said Andrea Stark, a Medicare consultant with
MiraVista LLC in Columbia, S.C. “It specifically says
providers cannot be involved.”

Indeed, as stated in the originally issued LCD, the ruling is
clear: “No aspect of an HST, including but not limited to
delivery and/or pickup of the device, may be performed by a DME
supplier,” it reads.

Stark said she was slightly disappointed in that mandate.
“I think it is an unnecessary restriction. DME providers are
uniquely prepared to do that kind of [delivery and pickup],”
she said. “The whole thing was about accessibility for the
patient.”

The newly revised version is the result of controversy over the
earlier LCD, published without public comment on July 17. Set for
implementation on Sept. 1, it followed CMS’ national coverage
determination issued in March.

Stakeholders, however, raised numerous issues about the LCD,
saying that it restricted access, particularly in rural areas, and
was released without the benefit of public comment even though it
contained numerous new policy mandates. In August, the DME MACs
elected to postpone its implementation.

“Implementation was delayed until contractors (such as
Cigna Government Services) received official notification from the
Centers for Medicare and Medicaid Services of the new national
coverage determination and instructions on what changes to
implement,” explained Robert Hoover, M.D., medical director
for Jurisdiction C. “Although a formal comment process was
not required, the DME MAC medical directors received feedback from
the provider community and delayed the implementation of certain
provisions pending further review.”

Stark said even though the newly revised version also was not
held up for public comment, “I think the changes are going to
be livable for most providers.”

Walt Gorski, vice president of government affairs for the
American Association for Homecare, which had questioned the absence
of a public comment period, said the association was in the process
of reviewing the new LCD to determine how suppliers can move
forward under its terms.

Meanwhile, stakeholders applauded other provisions of the
revised policy.

For example, providers can now document compliance either by
“direct download from equipment or by visual inspection of
adherence information,” the LCD says.

“The biggest thing that jumped out at me is that we can do
a visual compliance reading to determine if the patient is really
in compliance. That’s definitely a good thing,” said
provider Patrick Clevidence, vice president of respiratory services
for Medical Services Company in Cleveland, Ohio.

According to the LCD: “Documentation of adherence to PAP
therapy shall be accomplished through direct download or visual
inspection of usage data with documentation provided in a written
report format to be reviewed by the treating physician and included
in the beneficiary’s medical record. This information does
not have to be submitted with the claim but must be available upon
request.”

“You can actually get information from the hour meter; you
don’t have to have a download. Before, you were actually
going to have to buy the more expensive CPAP model, which, in some
cases, can be $200 to $250 more,” Clevidence said.
“Now, we won’t have to inconvenience the patient by
having them send in their Smart card, have someone here download
it, print out the information and send it out to the
physician’s office.”

Riley added that “a huge burden was taken off the
provider,” noting that with the previous LCD, “there
was a huge number of providers that really knew their costs that
said, ‘We simply cannot accept assignment from
beneficiaries.’ I’m not going to say this is totally
going to go away, but this is a warmer, kinder version.”

In addition, the newly revised LCD relaxes the requirements for
educating the beneficiary about HST.

“Patient instruction may be accomplished by 1)
face-to-face demonstration of the portable sleep monitoring
device’s application and use; or 2) video or telephone
instruction, with 24-hour availability of qualified personnel to
answer questions or troubleshoot issues with the device,” the
LCD says.

But it also stipulates, “This instruction must be provided
by the entity conducting the HST and may not be performed by the
DME supplier.”

Stark noted that the new LCD also stretches out the time period
for patients who must switch PAP devices in midstream. “If
they switch on day 90, they have until day 120 to prove compliance
and adherence,” she said.

As well, she noted, the LCD puts in place requirements for
physician education.

Effective Nov. 1, 2008, all HSTs must be interpreted by a
physician who meets one of the following four criteria:

1. Current certification in sleep medicine by the American Board
of Sleep Medicine;

2. Current subspecialty certification in sleep medicine by a
member board of the American Board of Medical Specialties; or

3. Completed residency or fellowship training by an ABMS member
board and has completed all the requirements for subspecialty
certification in sleep medicine except the examination itself and
only until the time of reporting of the first examination for which
the physician is eligible; or

4. Active staff membership of a sleep center or laboratory
accredited by the American Academy of Sleep Medicine or the Joint
Commission.

Physicians interpreting facility-based sleep tests must meet one
of those four criteria by Jan. 1, 2010, according to the new
LCD.

HME providers, Stark advised, should ensure that the “the
individuals you are getting these results from have their
credentials in place in order for you to be covered.”

The LCD also has established an ICD-9 code of 327.23 as the
specific code for obstructive sleep apnea.

“They are not allowing for any other derivatives of sleep
apnea or non-specific codes,” Stark said. “So this will
be a big issue.”

According to NHIC, the DME MAC for Jurisdiction A, “ICD-9
code 327.23 should be used on all claims at this time for patients
with obstructive sleep apnea.”

AAHomecare will hold a teleconference, “CPAP Versus PAP
Coverage: Where It Is and Where It Is Going,” with Stark as the
featured speaker tomorrow from 2 to 3:30 p.m. ET. For information,
visit www.aahomecare.org.

Stark will also hold a teleconference on the new LCD,
“Breathe Easier Knowing CPAP and RAD Regulations,” from
2 to 3 p.m. ET on Oct. 21. For more information, contact [email protected].

In addition to the LCD for PAP devices, the DME MACs also
revised the LCDs for lower limb prosthesis and wheelchair options
and accessories, and are proposing new policies for heating pads
and heat lamps, oral appliances for obstructive sleep apnea and
transcutaneous electrical joint stimulation devices.

For FAQs on the PAP LCD, a summary of its revisions and the
additional policy proposals, click here for the NHIC Web site.