Last Modified: 7/21/2020
Location: FL, PR, USVI
Business: Part B
Revised July, 2020
Medicare can make payment for Positive Airway Pressure (PAP) devices and related accessories when the patient's medical record shows the patient has obstructive sleep apnea (OSA) and meets medical documentation, test results, and health conditions as specified in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-03, Section 240.4
and the Durable Medical Equipment (DME) Local Coverage Determination (LCD) L33718
Medicare’s coverage for PAP devices and accessories begins with a 12-week trial period. In order for a DME supplier to provide the PAP device, the following must take place:
1. You must have an in-person evaluation with your patient to discuss any sleep-related issues they have. During this encounter, you should document pertinent information such as sleep disordered breathing (i.e., snoring, daytime sleepiness, observed apneas, choking or gasping during sleep, morning headaches), the duration of those symptoms, and may ask the patient to complete a validated sleep hygiene inventory (i.e., Epworth Sleepiness Scale). When applicable, a pertinent physical examination that includes body mass index, neck circumference, upper airway exam and cardiopulmonary exam will be part of the encounter medical record.
2. Following the in-person evaluation, you must order a facility-based polysomnogram or a Type II, III, or IV home sleep study demonstrating an Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) greater than or equal to 15 events per hour with a minimum of 30 events or an AHI or RDI greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of excessive daytime sleepiness, impaired cognition, mood disorders, insomnia or hypertension, ischemic heart disease or history of stroke. Note that for Medicare, hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds associated with at least a 30% reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a 4% decrease in oxygen saturation. In addition, respiratory effort-related arousals (RERA) are not included in the AHI/RDI calculation. This sleep study must take place on or after the date of the in-person encounter documenting signs and symptoms of OSA. The sleep test must then be interpreted by a physician/non-physician practitioner who meets the credentialing requirements as outlined in LCD L33718 (i.e., current certification in Sleep Medicine by the American Board of Sleep Medicine).
3. If the sleep test interpretation indicates a diagnosis of OSA and you feel the patient would benefit from PAP therapy, you may order a PAP device and related accessories. When your patient arrives at the DME business, their staff will fit them with a PAP device, provide them with the appropriate accessories (i.e., humidifier, mask, tubing, etc.), and review the use and care of the equipment with them.
The preceding steps will allow the DME supplier to bill Medicare for three rental months of the PAP device and related accessories.
Between the 31st and 91st day after initiating PAP therapy, your medical record documentation must show a face-to-face re-evaluation with your patient to assess the benefit of PAP therapy. You should review how symptoms of OSA have decreased and how the PAP device has helped your patient. Your medical record documentation must also demonstrate the patient is adhering to the therapy and that you have reviewed this adherence. Adherence to therapy is defined as usage of the PAP device greater than or equal to 4 hours per night on 70% of nights during a consecutive thirty-day period any time during the first three months of initial usage. Documentation of the patient's adherence to PAP therapy can be accomplished by your review of information maintained on the PAP device via visual inspection, data downloaded from the PAP device, or access from web-based sites with data transmitted from the PAP device. This information must be maintained in your patient's medical records and made available upon request.
The face-to-face re-evaluation does not have to be completed by the medical professional who ordered the PAP device. It can be completed by another physician or non-physician practitioner following the patient. For example, if a sleep specialist ordered the PAP device, but the patient goes to their primary care physician two months later, that would be acceptable and meet the Medicare requirement for the re-evaluation.
The standard written order (SWO) for the PAP device must contain the following:
• Beneficiary’s name or Medicare Beneficiary Identifier (MBI)
• Order date
• Description of the item(s) ordered
• Quantity to be dispensed, if applicable
• Treating practitioner name or national provider identifier (NPI)
• Treating physician’s signature
The DME supplier will most likely send you an SWO that lists all of the PAP accessories that can be billed to Medicare. Please review, sign and date that SWO in a timely manner so the DME supplier can file claims to the Medicare program.
Following these coverage guidelines will help your patients and the Medicare program by verifying that there is medical documentation to support the provision of a PAP device and allow your patient to receive the therapy needed to treat OSA. Your assistance will allow Medicare to pay claims appropriately and ensure that your patient receives the DMEPOS items you have prescribed.
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