Funding Focus

Reimbursement for RAD: What to Remember

• By Kelly Riley
• Mar 01, 2009

For weeks, the industry has focused on the oxygen issue following the posting of the latest policy revision by the Centers for Medicare & Medicaid Services (CMS) in late October. It now seems like long ago that the industry also was handed some significant changes for positive airway pressure devices. While we continue to focus on the biggest fire of the moment, we may be letting revenue streams dry up in other product categories by simply not putting the necessary revenue qualification steps in place.

Many obstructive sleep apnea (OSA) patients start on continuous positive airway pressure therapy (CPAP), but there will always be a portion of patients that go straight to a bi-level device. Others will need to change to bi-level after being on CPAP on the recommendation of their physician.

Bi-level therapy, referred to as respiratory assist devices (RAD) by CMS, offers several documentation challenges that must be met in order for payment to occur. These devices come with a backup rate (a component to add a breath or breaths) or without a backup rate (without the ability to add a breath and to simply provide pressure on both inspiration and exhalation). The HCPCS codes are E0471 and E0470, respectfully.

Since the RAD device with a backup rate is not considered medically necessary for the treatment of primary OSA by CMS policy, payment for this device is covered under a separate RAD policy. RAD devices with a backup rate billed with a primary diagnosis of OSA will be paid at the lower rate for code E0470. In cases where there is no documentation of a CPAP trial that proved ineffective in either a home or facility setting, the reimbursement would be further downcoded to CPAP (E0601).

Often our industry links the HCPCS codes to specific inventory items, which can present challenges when devices on the shelf have a similar outward appearance. This is especially true for bi-level devices. Anytime a device can be downcoded by Medicare, it is important to verify that the more expensive device was ordered by the doctor and is truly what the patient needs.

To fully understand the RAD guidelines, it is necessary to have a solid grasp of the payment policy for CPAP. The policy, in part, states that a single level CPAP device (E0601) is covered for the treatment of OSA if criteria A-C are met:
A. The patient has a face-to-face clinical evaluation by the treating physician prior to the sleep test to assess the patient for obstructive sleep apnea.
B. The patient has a Medicare-covered sleep test that meets either of the following criteria:

1. The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events; or
2. The AHI or RDI is 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:
   a. Excessive daytime sleepi ness, impaired cognition, mood disorders or insomnia; or
   b. Hypertension, ischemic heart disease or history of stroke.

C. The patient and/or caregiver have received instructions from the supplier on the CPAP device and accessories and the proper use and care of the equipment.
A RAD without a backup rate (E0470) is covered for those patients with OSA who meet criteria A-C and D:
D. A single level (E0601) positive airway pressure device has been tried and proved ineffective based on a therapeutic trial conducted in either a facility or in a home setting.

In the event the physician changes a patient's therapy from continuous pressure to bi-level pressure (no backup rate), there are some timelines that need to be adhered to. If the CPAP is changed to bi-level before the 91st day of therapy, the length of the trial does not change — re-evaluation occurs between the 31st and 91st day of initiation of CPAP. Only in the event that less than 30 days remain in the trial period can the period be extended. However, the face-to-face re-evaluation must occur before the 120th day following the initiation of CPAP.

If a CPAP has been used for more than three months and the physician determines that the patient needs to be changed to a bi-level device, a new face-to-face evaluation is required prior to the switch. A new sleep study is not required. A new three-month trial period would begin, and documentation of adherence to therapy during the three-month trial must be acquired.

Under these policies, patients certainly will need to be more involved in the process or it could cost them and the provider unexpected and unintended loss of revenue.

This article originally appeared in the Respiratory Management March 2009 issue of HME Business.