Funding Focus

Protecting Your Payments

How to ensure PAP documentation passes CERT adutors' muster.

When the first major changes were implemented to the LCD policy for Positive Airway Pressure (PAP) in November of 2008, most HME suppliers wondered how they would be able to implement those changes and still have any revenue left. More than two years later that concern isgreater than ever.

As suppliers work to obtain documentation, they are finding that despite their best efforts what documents they have still do not meet with the intent of the LCD as interpreted by the CERT auditors, as well as others. Audits are in high gear and if your company has not yet been though the process, it is only a matter of time, as audits are expected to ramp up even more in 2011.

Far too many orders aregeneric in nature and simplystate “supplies as needed,”but this practice will notsurvive an audit.

In order to keep your money, inspect your PAP patient records to show compliance in the following proven risk areas:

The Patient Saw a Qualified Provider

Evidence that the patient was seen by a qualified provider (doctor, ARNP, PA) before the patient was seen in the lab (or had the home sleep study) who documented in his notes (that you have a copy of) why the patient was sent to a sleep lab for a work up. Look for comments such as excessive daytime sleepiness (might be noted as hypersomulence), snoring, headaches, complaints bed partner. This combined with patient weight, and vital signs should be a start of proving a need, which is what the payors are looking for.

If the patient weight or blood pressure are outside of normal ranges, circle it on the document to indicate such. When the referral is originally sent to you from a sleep lab, ask who the referring primary care practitioner(PCP) was so that you can contact them toobtain the notes and ensure their validity in comparisonto the policy requirements.

Who is Following-Up?

Then ask the lab (or whomever sends the referral) who will be following up with the patient and the therapy after PAP setup is completed. It is important to note this early in the process. Doing so will ensure that you are not chasing documents from the wrong provider for notes required for the “follow up exam” that must take place after therapy application.

This visit must fit a specific time frame: no sooner than day 31 of therapy, but before day 90. These notes must come from the doctor’s records and cannot be any document that you the supplier send for signature. These notes are also critical to insure the provider keeps the money for rental claims beyond month three.

Look at these notes closely. They need to document that the patient is using and benefiting from the therapy and that the doctor reviewed the download of compliance data from the PAP device. Many chart notes are missing this element. Many think that having a download in the chart that demonstrates compliance is sufficient. However many such claims have been denied because the doctor’s review is missing. Look for comments such as “reports snoring less,” “sleeping better,” “less headaches,” “more alert throughout the day,” any of these observations would lend toward evaluation of successful therapy.

Other “physician documents” that are prone to problems are the sleep study itself. For years the only area the HME providers historically looked at was the AHI/ RDI measurement to see that it met the metric that defined medical necessity as designated in the LCD. Many providers refused to set up patients without a copy of the study. While that is a good policy, the problem now lies in the fact that getting the sleep study in that time frame generally gets a study that has not been signed by the doctor, yet gets filed away.

A Qualified Signature

There should be a process in place to ensure that the QC/documentation department obtains a signed copy once it becomes available. When looking for a signature validate the physician is qualified per the policy.

While there are some other areas that qualify, the easiest place to start is by checking to ensure they are boarded in sleep medicine. Usually they will attach credentials such as FACCP (Fellow American Board of Chest Physicians) Diplomat, ABSM, (American Board of Sleep Medicine), or others behind the MD or DO with their name. Note that internal medicine and pulmonary/critical care medicine are member boards of ABIM (American Board of Internal Medicine) and ABMS (American Board of Medical Specialties).

In order to save your money from audits, inspect your PAP patient records to show compliance in proven risk areas.

If you do not see these extra letters, try to obtain out a business card, phone book listing, web site, or simply call the physician’s office and ask for such an item. You can also check online by logging into: (you must create an account, then log in and search the listings by a physician’s last name).

Complete, Specific Orders

All orders for the therapy need to be complete and list every item that you intend to bill for. The order should also list the replacement schedule for each item. For example, “Replace mask every three months, cushions every two weeks, headgear and hoses every six months.”

Far too many orders are generic in nature and simply state “supplies as needed,” but this practice will not survive an audit. While that order might make sense to you (and the ordering doctor) it does not make sense to the payor, they want to see that items are not being added at the providers whim. Specificity and duplication in every document, while burdensome will keep the money in the bank.

This article originally appeared in the February 2011 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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