CPAP Documentation

The number of obstructive sleep apnea (OSA) patients is growing every year, and the demand for HME providers to enter the sleep market is growing, too. If you are involved in this area, your intake and billing personnel must understand exactly what qualifies a patient for continuous positive airway pressure (CPAP) therapy and/or supplies and what documentation is required for reimbursement.

When a referral calls you for a CPAP (HCPCS code E0601), your intake form should ask specific questions to make sure the patient qualifies under Medicare guidelines. Also remember that private insurance carriers all require different documentation, so it is vital that your insurance verification form is appropriate for the payer and that it is completed thoroughly.

First, make sure the patient has a diagnosis of OSA, then find the apnea-hypopnea index (AHI). The AHI is the average number of episodes of apneas and hypopneas per hour of sleep. The patient's polysomnogram (sleep study) must be based on a minimum of two hours of recording time without the use of a CPAP device. This result may not be extrapolated or projected in any way, and must be documented by an attended, facility-based polysomnogram.

You may not perform the sleep study, and you must be sure it is not performed in a mobile or home environment.

To qualify, the patient must have a total AHI of 15 or more events per hour. Or, the patient must have an AHI between five and 14 events per hour with the documented symptoms of insomnia, moodiness, excessive daytime sleepiness, impaired cognition, or ischemic heart disease, history of stroke or hypertension. This must be documented on the physician's order, and you must maintain a copy of the sleep study in the patient's file.

Once you take the order, check the “true” results on the sleep study to verify that the AHI results are the same as what you were told at intake. Some physicians may give apnea episodes per old policy or the Respiratory Disturbance index, which must be calculated to the AHI.

The CPAP and supplies require a “KX” modifier when billing and transmitting these claims to the DMERC. This means that you have the documentation in your files prior to transmitting these claims to the DMERC. Often, in auditing files I find that billers have added a KX modifier because they know they will receive a CO-50 (not medically necessary) denial if it is omitted, but they do not have the correct documentation in the file.