Reimbursement Corner – PAP Policy Reminder, O2 Equipment Policy, Severe COPD and Ventilators Discussed

Posted on in Billing/Reimbursement

ReimbusementCorner_Ronda By Ronda Buhrmester, VGM Reimbursement Team PAP Policy Reminder for Continued Coverage Beyond Third Month In regard to continued coverage beyond the first three months, the PAP policy states the following: For PAP devices with initial dates of service on or after Nov. 1, 2008, documentation of clinical benefit is demonstrated by:

  1. Face-to-face clinical re-evaluation by the treating physician with documentation that symptoms of obstructive sleep apnea are improved; and,
  2. Objective evidence of adherence to use of the PAP device, reviewed by the treating physician.
Adherence to therapy is defined as use of PAP =4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. What does this mean? How does Medicare know that the treating practitioner has reviewed the “objective evidence of adherence to the PAP device”? What this means is making sure to get a copy of the compliance report to the patient’s treating practitioner prior to the re-evaluation. The practitioner must reference the compliance report in the progress notes or sign the compliance report to prove the practitioner reviewed the report. Suppliers have been receiving denials in regards to this criteria. By having the practitioner sign the compliance report or reference it in the progress notes, this is letting Medicare know this criteria has been met.
  Oxygen Equipment Policy – Pneumonia Covered or Not?? The oxygen policy states that when testing is performed for a patient, the testing must be done while the patient is in a chronic stable state OR within two days prior to discharge during an inpatient hospital stay. There has been many questions about the diagnosis of pneumonia being used when the patient is being discharged the hospital. What does this mean? Can the diagnosis of pneumonia work for a patient whom is being discharged from the hospital? NO! Medicare considers coverage for home oxygen when the patient has a chronic lung condition. Coverage for home oxygen needed for a short-term therapy due to an acute illness such as pneumonia would not be considered for payment. Coverage is considered for a patient with an acute exacerbation of a chronic lung condition if the qualifying test is done on an inpatient basis within two days prior to discharge and the most recent oxygen testing must be used. Home oxygen is used for long-term therapy, not a short-term basis.
  RAD policy: Severe COPD Coverage for E0470 Under the revised policy that took effect Dec. 1, 2014, for severe COPD coverage for an E0470, these are the following requirements:
  1. ABG PaCO2, while awake and breathing patient’s prescribed FiO2 greater than 52 mm Hg; AND
  2. Sleep oximetry demonstrates oxygen saturation of less than or equal to 88 percent for greater than or equal to a cumulative 5 minutes of nocturnal recording time (minimum recording time of 2 hours), done while breathing at 2 lpm or the patient’s prescribed FiO2 (whichever is higher); AND
  3. Prior to initiating therapy, sleep apnea and treatment with CPAP has been considered and ruled out.
    • Formal sleep testing is not required if there is sufficient information in the medical record to demonstrate that the beneficiary does not suffer from some form of sleep apnea (Obstructive Sleep Apnea (OSA), CSA and/or Comp SA)
What does this mean? Many suppliers have struggled getting criteria No. 2 above met under this policy. The fact that criteria No. 2 is not accomplished does not mean the patient qualifies for a non-invasive ventilator (NIV). The policy is not specific as to when the testing needs to be performed, such as upon discharge. What needs to happen is have the testing performed upon admission when the patient is sick. This is when they will more than likely meet the coverage criteria. Let the referrals, such as nurses, case managers, discharge planners, hospitalists, etc., know that if they have a patient that they may be a candidate for a RAD device upon discharge, to start the testing when the patient is admitted to the hospital.
  Ventilators—Good Documentation a MUST Ventilators, invasive and non-invasive, have been getting a lot of attention lately by both suppliers and the Medicare contractors. We all know there isn’t a medical policy to follow, but there are the basic rules of thumb that can be followed.
  1. Rule out the least costly alternative
  2. Make sure there is good, clear, thorough documentation that indicates the medical necessity for the item being ordered.
Of course, there is the detailed written order, other supporting documentation, test results, etc., that are also important to obtain prior to delivery. However, there is a need to review the documentation requirements because many suppliers have been feeling the audits and denials. The most recent denials on an NIV (E0464) with either a COPD or ALS diagnosis have stated the following: “The submitted documentation does not verify that the severity of the beneficiary’s qualifying condition is such that he/she cannot tolerate being off a ventilator for a period of more than 10-15 minutes.” “The submitted documentation did not confirm that the severity of the beneficiary’s qualifying condition is such that he/she cannot tolerate being off a ventilator for a period of more than approximately 1-2 hours.” What does this mean? A ventilator is necessary for patients whose life is at risk if they are away from the ventilator for as much as two hours. This is why ventilators are categorized as frequent and substantial servicing—life supporting/sustaining equipment. Now the supplier can still appeal these denials if they disagree with the review. The bottom line is make sure the medical record indicates whether it would be life-threatening if the patient discontinues using. And is especially important for nocturnal use only patients. Please contact me with any questions. Ronda Buhrmester, CRT Reimbursement Specialist O: 888-665-6518 F: 855-262-3821 Twitter: @RondaBuhrmester