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.
Since there is no Certificate of Medical Necessity for CPAPs and supplies (discontinued in 2002), you are responsible for making sure you have the required documentation.
Once the patient qualifies, you must verify between the 61st and 90th day that the patient is using the equipment and has found it to be medically beneficial prior to adding the KX modifier in the fourth month of billing. If you do not get the documentation from the patient or physician, you must hold these claims until it is obtained.
This information can be in written form, or verbal — as long as you document thoroughly that the patient or physician has been contacted and you have a log in your files stating what was asked and what answers were received. Once you obtain this information, you can add the KX modifier in the fourth month and continue billing.
CPAPs are in the capped rental category, so the CPAP will bill as long as the patient medically needs and is using the equipment, or through the 15th month if the patient chooses the rental option in the 10th month. You must give the patient the “Tenth Month Purchase Option Letter” in the 10th month, and allow him to select whether he would like to purchase or continue renting. If he continues renting, the equipment is yours.
If the patient decides to purchase the CPAP, you will bill through the 13th month — and the patient now owns the equipment. Make sure, per the 21 Supplier Standards, that you give the patient a copy of the equipment warranty, and document that you have done so. If the patient chooses the rental option, you bill maintenance in the 22nd month, then every six months as long as the patient needs the equipment. Intake and billing personnel must understand exactly what qualifies a patient for CPAP therapy and/or supplies and what documentation is required for reimbursement.
Jane Bunch is CEO of Kennesaw, Ga.-based JB&CS. 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 BILLHME@aol.com.
