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Sleep Apnea Resources

Below you will find valuable sleep apnea-related resources, including Medicare information for ordering/treating physicians, frequently asked questions and answers regarding PAP therapy for Medicare beneficiaries, downloadable patient materials, and more. 

 

 

Important Medicare Information for Ordering/Treating Physicians

On November 1, 2008, a new Local Coverage Determination (LCD) for Positive Airway Pressure therapy for the treatment of Obstructive Sleep Apnea was implemented by all four DME MACs. The following information highlights the new responsibilities of the ordering/treating physician. These policy changes ONLY apply to traditional Medicare fee-for-service patients covered by Part B. They do not apply to most managed care organizations patients.

In addition to a positive diagnosis of Obstructive Sleep Apnea (327.23) via a Medicare-covered sleep study, 2 face-to-face evaluations are required for initial and continued Medicare coverage for PAP therapy.  

Face-to-Face Evaluation 1: There must be a face-to-face evaluation with the treating physician prior to ordering any sleep test. This may include documentation of the following in the patients medical record:

  • Sleep history and symptoms
  • A standardized patient questionnaire which helps to assess the likelihood of sleep apnea
  • Pertinent physical examination e.g., body mass index, neck circumference, upper airway exam, and cardiopulmonary exam

Face-to-Face Evaluation 2: Following the set-up of the device, the patient must see the treating physician again, sometime between the 31st and 91st day, to document whether there has been improvement in the patients symptoms.

  • The physician must review data from the PAP device. For a patient to qualify for Medicare coverage, the device must document use at least 4 hours per night on 70% of nights for a 30 consecutive day period during the trial.

Medicare coverage of the PAP device beyond the first 3 months is contingent upon demonstration of patient benefit from the use of a PAP device and your documentation of these face-to-face evaluations. Apria Healthcare will provide you with PAP usage information for the Medicare beneficiaries you have entrusted to our care for the treatment of Obstructive Sleep Apnea. We will also provide you with the documentation we require for your review and signature to ensure continued coverage of therapy for your patient. 

Medicare Beneficiaries Converting to BiLevel

The Medicare LCD for Positive Airway Pressure Devices for OSA also outlines the following criteria for coverage of BiLevel therapy for patients with a diagnosis of Obstructive Sleep Apnea:

  • Patient must meet all initial coverage criteria for CPAP
  • CPAP must be tried and proven ineffective based on a therapeutic trial conducted in either a facility or in a home setting. Ineffective is defined as documented failure to meet therapeutic goals using a CPAP during the titration portion of a facility-based study or during a home use despite optimal therapy (i.e., proper mask selection and fitting and appropriate pressure settings).
  • Physician must document in the patients medical record that both of the following issues were addressed prior to changing to a BiLevel device.
    1. Interface Fit and Comfort. An appropriate interface has been properly fit and the beneficiary is using it without difficulty. This properly fit interface will be used with the BiLevel device.
         AND
    2. The current pressure settings of the CPAP prevent the beneficiary from tolerating the therapy and lower pressure settings of the CPAP were tried but failed to:
      1. Adequately control the symptoms of OSA;  or
      2. Improve sleep quality; or
      3. Reduce the AHI/RDI to acceptable levels

Substitution of a BiLevel within the initial 90-day trial period does not require a new face-to-face evaluation or new sleep study.

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PAP Therapy and Medicare: Frequently Asked Questions

Q. What is the definition of a treating physician?
A. Medicare defines a treating physician as one who furnishes a consultation or treats the beneficiary for a specific medical problem and who uses the (diagnostic x-ray test, diagnostic laboratory test and other diagnostic test) results in the management of the beneficiarys specific medical problem. If the beneficiary visits his/her primary care provider (PCP), who then refers the beneficiary to a sleep specialist for a polysomnogram and subsequent treatment with PAP and follow-up, both the PCP and the sleep specialist would be considered a treating physician within the context of Medicare regulations. Both physicians are engaged in diagnosing and treating the beneficiary for sleep disordered breathing. This scenario is quite common in medical practice where the primary medical care for the patient is rendered by the PCP and subspecialty physician consultation is engaged for specific diagnostic and/or therapeutic treatment outside the scope of the PCPs area of medical expertise.

Q. Are nurse practitioners, clinical nurse specialists, and physician assistants allowed to conduct the initial clinical evaluation and/or follow-up evaluation since the LCD states this must be done by the treating physician?
A. Yes. Medicare regulations provide for the use of nurse practitioners, clinical nurse specialists and physician assistants in the care of Medicare beneficiaries. Section 1861(s) of the Social Security Act defines the provision of medical and other health services as follows:
 

  • Physician Assistants: (2)(K)(i) services which would be physicians services if furnished by a physician and which are performed by a physician assistant under the supervision of a physician and which the physician assistant is legally authorized to perform by the State in which the services are performed, and such services and supplies furnished as
    incident to such services as would be covered if furnished incident to a physicians professional service, but only if no facility or other provider charges or is paid any amounts with respect to the furnishing of such services.
  • Nurse Practitioners and Clinical Nurse Specialists: (2) (K)(ii) services which would be physicians services if furnished by a physician and which are performed by a nurse practitioner or clinical nurse specialist working in collaboration with a physician which the nurse practitioner or clinical nurse specialist is legally authorized to perform by the State in which the services are performed, and such services and supplies furnished as an incident to such services as would be covered if furnished incident to a physicians professional service, but only if no facility or other provider charges or is paid any amounts with respect to the furnishing of such services. 

Q. Can a registered nurse (RN) conduct the follow-up evaluation?
A. No, the treating physician (defined and discussed above) must be directly involved in the follow-up evaluation.

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Manuals, Patient Education, and Downloadable Materials

Click below if you are looking for manuals, patient education materials, Medicare information, and more:

 

Click here for a list of sleep equipment available from Apria.

CPAP or BiLevel Order Form

 Click here to download the Fax Order Form form CPAP or BiLevel.

Contact your local Apria branch to get your branch fax number for submitting the form back to us.

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Professional Sleep Websites

  1. NCSDR: http://www.nhlbi.nih.gov/about/ncsdr/profedu/profedu-a.htm
  2. American Academy of Sleep Medicine: http://www.aasmnet.org/
  3. SleepEducation by AASM: http://www.sleepeducation.com/

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Manufacturers' Websites

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