Medicare can make payment for PAP equipment and supplies when the patient's medical record shows the patient has 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, Medicare National Coverage Determinations (NCD) Manual, Section 240.4.
Medical record documentation determines whether your patient can receive the PAP equipment and supplies you have prescribed and the amount of the patient's out of pocket expenses.
Medical record documentation must show an in-person or face-to-face interaction with your patient within six (6) months prior to prescribing the item, specifically to document the patient was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered. For the initial evaluation, the report would commonly document pertinent information such as – signs and symptoms of sleep disordered breathing including snoring, daytime sleepiness, observed apneas, choking or gasping during sleep, morning headaches; the duration of those symptoms and a validated sleep hygiene inventory, but may include other details as well. Also a pertinent physical examination assessing – e.g., body mass index, neck circumference, upper airway exam and cardiopulmonary exam. It is not necessary for all of the above to be present; however it is critical that there be detailed information that identifies symptoms commonly associated with OSA. Multiple treating practitioners may be involved in patient care. The practitioner conducting the face-to-face visit may be different than the ordering practitioner, however the ordering practitioner must have access to evaluate the medical record.
Your patient must have a facility-based polysomnogram or a type II, III, or IV home sleep study after your in-person evaluation, demonstrating an AHI or RDI greater than or equal to 15 events per hour with a minimum of 30 events per hour 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. This sleep study must take place on the same date or after the in-person or face-to-face interaction documenting signs and symptoms of OSA.
The prescription must include a detailed description of the item(s) being ordered. The order must also include the order date, patient name, your name, NPI, signature and signature date. You must supply this signed order and the medical record documentation of your face-to-face evaluation to the supplier before they can deliver the PAP device to your patient. Please note that while PAP accessories may be provided from a dispensing order, this must be followed up with an order containing a detailed description for each item provided to your patient.
Your medical record documentation must also show a face-to-face re-evaluation with your patient between the 31st and 91st day after initiating therapy with a notation that the patient’s symptoms of OSA are improving. 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 use of the PAP greater than or equal to four hours per night on 70 percent of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage.
Following this guidance 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 their condition. Your assistance will allow Medicare to pay claims appropriately and ensure that your patient receives the device and accessories you have prescribed.
