Funding Focus

The New PAP LCDs: Are You Ready?

• By Kelly Riley
• Sep 01, 2008

Editor’s Note: Following is Part I of a two-part series on the new LCDs for PAP therapy.

With the recently published and long-awaited CPAP local coverage determinations (LCDs), the intake, billing and reimbursement departments will require some new checks and balances if providers have any expectation of payment. That’s because the LCDs, which apply to dates of service on or after Sept. 1*, include newly imposed hoops for the provider to jump through in order to file a clean claim. The following hoops, which will need to be cleared first by intake staff or customer service, include the collection of documents that must be in a provider’s files. These documents must reflect that the patient had a face-to-face evaluation prior to the sleep test.

• Physical assessment and documentation of patient Body Mass Index (BMI), neck circumference, focused upper airway and cardiopulmonary evaluation
• Epworth Sleepiness Scale (ESS)
• Sleep history, detailing symptoms that include snoring, daytime sleepiness, observed apneas, choking or gasping during sleep and morning headaches.

Other hoops for intake staff involve a credentialing verification process. The sleep test can only be interpreted by a physician who is a diplomat of the American Board of Sleep Medicine (ABSM), a diplomat in sleep medicine by a member board of the American Board of Medical Specialties (ABMS), or an active staff member of a sleep center or laboratory accredited by the American Academy of Sleep Medicine (AASM) or the Joint Commission. Often providers face challenges getting copies of the sleep study in a timely fashion.

Now, they also will need to ensure that the physician is qualified per the LCDs. Add to this scenario that the first time customer service receives the copy of the physician notes from the face-to-face examination, the notes will more than likely read something like this: “Patient presents to get Rx refilled, complains of being excessively tired and spouse reports loud snoring.

Plan: Refer for sleep evaluation and study.” Missing from the notes is the BMI, neck circumference measurement, ESS and the other items now mandated. When calling the physician, providers often learn that the physician refers those tasks to the sleep doctor. Also, it is not unusual for patients to go directly to the sleep lab and not see the sleep specialist until after the study or at all.

Included in the LCD is the statement, “Suppliers are encouraged to help educate physicians on the type of information that is needed to document a patient’s need for PAP therapy.” Telling a physician what is to be included in the examination of the patient can be a daunting task. Many industry stakeholders at press time were entering into discussions with the DME MAC medical directors with hopes of getting clarification, as well as a bit of a reprieve, from these significantly more restrictive guidelines.

There has been argument that the new guidelines should have come with a comment period, as they were perceived as having very significant changes. Changes of this magnitude will take more than a few weeks of education to implement.The next set of hoops — and they are big ones — will have to be cleared by a provider’s reimbursement team. Those will be discussed in the next issue, along with some much needed clarification on the roles of the HME vs. the physician vs. the sleep lab. It is also beginning to look like the patient will have far more ownership in this process. Many providers have stated that this policy will force them to provide PAP equipment to Medicare beneficiaries on a non-assigned basis only. Given the hoops and no chance for a medal, who can blame them? At press time, implementation of the LCDs had been delayed.

This article originally appeared in the Respiratory Management Sept/Oct 2008 issue of HME Business.