Funding Focus

Interpreting the PAP LCD Revisions

When the long-awaited local coverage determinations (LCDs) for all four DME MAC regions were posted July 18, the entire sleep industry took a deep breath, or rather a gasp. Many believed the posted policy to be a very different version from what was articulated in the national coverage determination (NCD).

In response, many industry stakeholders, including AAHomecare, the American Association of Respiratory Care (AARC), Region C council as well as others, entered into discussions with the DME MAC medical directors. Inclusive in these discussions were messages that the industry was seeking a reprieve from what was felt to be challenging, if not impossible processes that the new policy mandated. Many providers openly expressed the position that under the new policy, it would be impossible to accept assignment on Medicare beneficiaries for PAP equipment.

Those efforts seemed to pay off when just days prior to the Sept. 1 deadline an announcement came out stating, “All criteria with a Sept. 1, 2008, implementation date are being delayed.” Then Sept. 18, a new policy with several revisions was posted with an extended deadline of Nov. 1.

Simply stated, even with these revisions, there are still many more hoops for a provider to jump through than the previous policy. Still, this version is more palatable than the policy issued in July. For example, gone is the wording on the physician face-to-face evaluation component that “the clinical evaluation by the treating physician must include, at a minimum, body mass index measurement (BMI), neck circumference, focused upper airway system evaluation, Epworth Sleepiness Scale evaluation (ESS), sleep history and symptoms including but not limited to snoring, daytime sleepiness, observed apneas, choking or gasping during sleep and morning headaches.” Under the new policy, the face-to-face evaluation by the treating physician must be performed “prior to the sleep test to assess the patient for obstructive sleep apnea.”

Gone is the requirement for devices that have data download capabilities. That has been revised to state that the DME MAC will accept “visual inspection of compliance data.”

Also gone is the requirement that the instruction for a home sleep test (HST) be done in a face-to-face setting. Now the policy allows for either face-to-face instruction or video/telephone instruction with 24-hour phone support.

Physicians who read these studies must meet the same credentialing requirements as previously set. For tests conducted in a lab, physicians have until Jan. 1, 2010, to meet those requirements. The rationale is that many physicians have been interpreting facility-based PSGs for years, and it does not make sense to suddenly preclude them Nov. 1. However, the Centers for Medicare & Medicaid Services (CMS), when questioned, stated, “The medical literature is clear. Home sleep tests are most accurate when interpreted by physicians skilled in the proper interpretation of these tests. Requiring interpreting physicians to demonstrate, through formal training and testing certification, competency in this field is consistent with the literature and technology assessment.”

Surprising to many was the change in the description of acceptable HST devices. Units that were specifically included in the NCD are now excluded by at least one of the LCDs. Others that had been excluded are now in. The change-up is noted in how the apnea-hypopnea index (AHI) and respiratory disturbance index (RDI) are measured. No longer is an indirect measurement acceptable.

Customer service representatives will need to be trained to scan for this documentation during the intake process, if a supplier is planning to accept Medicare assignment.

While these changes are not as stringent as those posted in the July version, there are still significant additional burdens for the provider to bear to ensure payment from CMS. With the additional MIPPA mandated 9.5-percent cut for this service, it may simply be too little too late.

PAP LCD Revisions

Under the policy segment of Indications and Limitations of Coverage:
l    Revised: Coverage criteria for documentation of initial evaluation and moved to Documentation section
l    Revised: Clarified extrapolation of AHI and RDI results
l    Revised: Definition of Type IV device
l    Revised: Extended implementation dates for credentialing of physicians interpreting home sleep tests and facility-based polysomnograms
l    Revised: Requirement for beneficiary education by entity conducting home sleep test
l    Revised: Expanded dates during which patients must be re-evaluated for documenting benefit from PAP therapy
l    Revised: Expanded dates for patients switched from CPAP to RAD with less than 30 days remaining in initial trial period
l    Added: Requalifying after failed initial 12-week trial of PAP therapy
Under the policy section on Documentation:
l    Revised: Expanded dates for documentation of benefit from PAP therapy
l    Revised: Documentation of adherence to PAP therapy to allow visual inspection of usage data

This article originally appeared in the Respiratory Management November 2008 issue of HME Business.

About the Author

Kelly Riley, CRT, is director of The MED Group's National Respiratory Network and has more than 25 years of experience in the respiratory arena.

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