Meeting New CMS CPAP Standards with Remote Monitoring

• By Dave Henry
• Sep 01, 2009

The world of sleep medicine has evolved rapidly in recent months. The new CMS standards have impacted and will continue to impact both the diagnostic and therapeutic practice of sleep medicine.

PAP therapy has long been considered a cost effective method of treating patients with sleep disordered breathing, including obstructive sleep apnea . There are now specific standards that CMS has outlined as acceptable practice and will be expected to be adhered to for reimbursement of PAP devices. Many times, these same standards, incorporated by Medicare, will then be adopted by other healthcare insurance companies as guidelines for reimbursement of PAP devices.
So the elements to be “adherent” to PAP therapy include:

• Objective proof of use of the PAP device for more than four hours per night.
• For 70 percent of the time.
• Within a 30-day consecutive window of time.
• Within a 90-day trial period on the PAP device.

In order for reimbursement to occur, objective proof of adherence must be collected. Presently, there are various technologies on the market that collect and store this data. Accuracy of the information may be questionable if the patient is asked to read this information to the homecare provider. In order to secure this information from being manipulated, a method of “coding” the data is used. When this information is requested from the patient during a telephone interview, the code is read and the accuracy of the data is protected. If the patient reads the code erroneously, the error will be exposed, and the patient will be asked to repeat the code.With reimbursement limited in many areas of the country, this method of having the patient read the code is very cost effective in collecting this data.

Remote adherence monitoring systems use a coding system. A number of select remote adherence monitoring systems will include all the elements required by Medicare for proving CPAP utilization by the patient. The threshold is greater than four hours per day. The device also screens the data for greater than 70 percent of time usage within a 30-day window within a 90-day trial.

A proactive protocol for achieving PAP adherence is really important to achieve patient acceptance of therapy. Followup early on is necessary to help the patient become adherent to the therapy which is well supported in the literature.

Interventions including mask adjustments, humidification, desensitization, and other techniques necessary to help the patient adjust to their PAP therapy can be helpful.
A suggested protocol might include:

I. Patient Set-up

A. Education — Patient views an OSA education video, and training is documented to the patient file.

B. Fitting and orientation

1. Fit interface and setup PAP device.

2. Show patient how to retrieve encrypted code and explain what to expect in terms of follow-up by phone. Obtain best time to call.

II. Three to six day follow-up

A. Call patient and retrieve the seven-day code. Generate report and discuss results with patient. Note: In order to retrieve data for days two through seven, the seven-day code must be used.

B. Help patient resolve any issues they might have.

C. If necessary, schedule an additional follow-up.

III. 45 day follow-up

A. Call the patient and ask the patient to relay the adherence score to you.

B. If the adherence score is more than 70 percent, retrieve the 90-day code from the PAP device.

C. If the patient does not show qualifying usage, then work with them to resolve any issues and encourage adherence.

D. Send report to referring physician and tell the patient to contact thephysician to schedule a re-evaluation.

“A proactive protocol for achieving PAP adherence is really important to achieve patient acceptance of therapy.”

IV. Finish patient files with documentation of re-evaluation. This protocol allows for early intervention and it assures that the patient is making progress in becoming adherent to therapy. (Customize this suggested protocol to your specific operation.) It also assures the patient’s adherence meets the criteria for reimbursement of the PAP device. If the patient’s adherence is met sooner than the 90- day trial, the homecare provider may bill the fourth month rental without delay. Of greatest importance is the improved patient outcome, which directly impacts the cost of care. Combining affordable technology and a usable clinical protocol helps guarantee acceptable patient outcomes and follows guidelines for reimbursement to providers.

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