Funding Focus

Getting Involved with HST: Why Are You Stalling?

• By Kelly Riley
• Jul 01, 2008

Home sleep testing, also known as portable monitoring, has been around for years, yet the recent National Coverage Decision (NCD) memo issued by the Centers for Medicare & Medicaid Services (CMS) has many folks squirming. The NCD allows payment for CPAP devices based on unattended studies vs. traditional in-lab studies. Most HME providers want to be ready, but without a published Local Coverage Determination (LCD) from the Medicare Administrative Carriers (MAC) medical directors, they are hesitant to set company policy, communicate to referral sources or develop marketing plans.

The hesitancy makes sense, especially since even with an NCD regarding coverage for CPAP, there has not been an NCD issued for polysomnography or the testing component. Without clear guidance on multiple issues — such as who is qualified to perform testing and bill for tests, the HCPCS code associated for each type of test, and the reimbursement for each test — it is wise to exercise prudence.

Frankly, without some assurances that the diagnostic component will be paid for at a reasonable amount and that the tests can be conducted by an entity other than a sleep lab, there really is no change from how things are currently being done. Adding to the confusion, some recent LCDs regarding the testing component (polysomnography and portable monitoring) from the Part B carriers conflict with the NCD. One MAC medical director reported that those LCDs were premature and likely to be revised. One must recognize the higher authority of CMS. Per the NCD, CMS has established the base rules for this class, including CPT codes. The changes will probably come through, just not in the timeframe most of us were expecting.

Also adding to the wait-and-see attitude is the fact that although the NCD was issued in March and the LCD was expected to follow within 90 days, the change request from CMS to the MAC medical directors has not been issued (at press time). Many assumed this occurred at the same time that the NCD was published. The medical directors have 90 days from the issuance of the change request to issue the LCDs. (See Respiratory Management May 2008, “LCDs: How and When They Affect You.”)

As we wait, providers should use this time to enhance their business model for sleep therapy. Gear up staff and educate referral sources on what is happening. A recent survey of several HME members revealed that only about 50 percent of sleep labs they worked with were fully aware of the changes related to the NCD memo. Get creative and find a way to partner with labs by sharing resources. For example, sleep labs are experts on the testing component, and HMEs are experts at tracking equipment, marketing services and working in the patient home environment.

Within your team, brainstorm about who your customer is and how that customer should be approached. Typically, the customer has primarily been the sleep lab; therefore, the lab should remain high on the list of priorities. The HME provider also has an opportunity to enhance disease outcomes by working with primary care practitioners and the general public. One in 15 people are predicted to have moderate to severe sleep apnea, and the National Sleep Foundation reports that only 15 percent of those with OSA have been treated. A huge opportunity exists for HMEs to establish themselves as advocates for early intervention of sleep-related breathing disorders.

Educate your team on the terms used in sleep diagnosis and treatment. Above all, know when a patient is not a candidate for unattended sleep studies. This will help establish your company’s credibility as a trusted partner within the health care team.

Learn the pros and cons of the different HST devices available. More channels of recorded data are not a plus if the device is too cumbersome or complicated for the average patient to self-administer. Providers that have been involved in the delivery of pulse oximetry units can attest to how simple the process must be in order to avoid costly repeat studies. Evaluate the acquisition costs of devices and the costs per study (probes, data retrieval, etc.). Ask manufacturers for benchmark data related to these issues.

While you’re waiting for the LCDs, use your time wisely; you may not get the chance later.

Author’s Note: References used in this article include: Somers, V.K., et al, “Sleep-disordered Breathing and Cardiovascular Disease,” Circulation, 2003; and Wolk, R., et al, “Obesity, Sleep Apnea and Hypertension,” Hypertension, 2003.

This article originally appeared in the Respiratory Management July/August 2008 issue of HME Business.