Keeping Up with Changes in the Sleep Market
In addition, a physical exam must be performed, which includes a focused cardiopulmonary and upper airway system evaluation, the patient's neck circumference and the patient's body mass index (BMI).
All of this information is required before the supplier can submit a claim for a CPAP or bilevel unit. In addition, it is interesting to note that the patient's face-to-face clinical evaluation must be conducted by the treating physician prior to the sleep test. It is vital that suppliers carefully review the clinical documentation they receive to be certain that all clinical notes that they rely on to document the physician face-to-face examination are notes that existed prior to the sleep test.
In addition to new requirements related to the physical exam, the LCD contains elements requiring the HME provider to verify that the interpretations provided by physicians meet minimum criteria. For dates of service after Nov. 1, 2008, all suppliers are required to verify that any home sleep tests used to qualify the patient are interpreted by a board-certified sleep physician, a board-eligible sleep physician or a physician with active staff membership at an accredited sleep facility.
By placing the burden on the HME supplier to verify that these requirements are met, CMS is opening the door for denials for CPAP devices if an improperly qualified physician interprets the sleep study.
For patients with dates of service after Jan. 1, 2010, physicians interpreting facility-based polysomnograms must meet all of the criteria listed above as well.
For continued coverage of a PAP device beyond the first three months, the patient must have a clinical reevaluation by the physician no sooner than the 31st day but no later than the 91st day after initiation of therapy. This clinical reevaluation should contain, at a minimum, a face-to-face examination by the physician with documentation that symptoms are improved and objective evidence of adherence to use of the PAP device. Adherence is defined as use of the PAP for greater than or equal to four hours per night on 70 percent of nights during a consecutive 30-day period.
Home Sleep Testing
According to the LCD for PAP devices, several types of home sleep test units are approved for qualification of Medicare patients. A Type II device measuring a minimum of seven channels, a Type III device measuring a minimum of four channels and a Type IV device measuring a minimum of three channels are all approved for qualifying Medicare patients for PAP therapy.