What Pro2 is Up2

According to DME MAC A, the Medicare Administrative Contractor for Durable Medical Equipment, more than two-thirds of all claims denied in their latest audit were denied because of issues with face-to-face clinical evaluation documentation.

DME MAC A reviewed claims processed between November 2011 and January 2012 for CPAP devices. Of claims that were denied, almost half (46.5%) were missing the required clinical documentation and medical records to support the medical necessity of the device.

"These claims had no Face to Face clinical evaluations from the beneficiaries' medical records. Included in these were no Face to Face evaluations conducted by the treating physicians where the beneficiaries were seeking PAP replacement following the 5 year RUL or when requiring coverage of a replacement PAP upon entering FFS Medicare."

About 20% of the claims that were denied had insufficient clinical documentation to support the medical necessity of the device, such as:

- No detailed narrative describing the presenting symptoms of sleep disordered breathing, daytime sleepiness/fatigue, observed apneas, choking/gasping during sleep; duration of symptoms; or Epworth Sleepiness Scale scores
- The face-to-face clinical re-evaluation failed to demonstrate an improvement in obstructive sleep apnea (OSA) symptoms and that the patient continued to benefit from PAP therapy
- Insufficient clinical documentation for face-to-face evaluations where the patient is seeking PAP replacement or when requesting coverage of a replacement PAP upon entering FFS Medicare

Finally, just over 6% of denied claims were missing the signature and/or date on the face-to-face evaluation and a handful had illegible documents.


Source: Results of Widespread Prepayment Review of Claims for HCPCS E0601, (Continuous Positive Airway Pressure Devices). NHIC, Corp. Retrieved August 20, 2012 from http://www.medicarenhic.com/dme/medical_review/mr_bulletins/mr_bulletin_pca/042012_cpap.pdf

On August 27, 2012 the American Academy of Pediatrics issued new recommendations for primary care practitioners regarding the diagnosis and management of obstructive sleep apnea syndrome (OSAS) in children and adolescents.

The new recommendations include the following:

- All children and adolescents should be screened for snoring
- A sleep study should be performed if the child or adolescent snores and presents symptoms or signs of OSAS
- If the child has enlarged tonsils, the first line of treatment is to have them removed
- If tonsils cannot be removed or are ineffective in treatment, then CPAP should be attempted
- Weight loss is also recommended for children and adolescents who are overweight or obese

If your child snores, it's important to discuss his or her condition with your child's primary care practitioner. Click here to read the full list of recommendations released.

CPAP (continuous positive airway pressure) can be a very difficult therapy to adjust to. But, with the right attitude and the help of a good support group, it can be made into an easier transition.

It's important for the patient to understand why the CPAP is needed and what health benefits are gained from correcting obstructive sleep apnea (OSA). At Pro2, a Respiratory Therapist reviews the sleep study with each patient to reiterate the findings made during the testing and to show the corrective outcome with continued use of the therapy.

Next comes the application of the mask and the subsequent pressure to follow. Talking with the patient and explaining the feelings he will have of resistance on exhalation is very important. Letting him know that the mask has an exhalation port and feeling the air escape from that mask helps him to realize he is able to exhale completely. Most patients are then able to relax within the first minute of therapy.

Each CPAP is also equipped with a ramp feature which allows the patient to press a button and initially reduce the pressure. The ramp pressure will slowly increase to the prescribed pressure all while giving the patient time to fall asleep and not even notice the gradual change. If at any time during the night the patient wakes up, we encourage the use of this comfort feature.

The use of the heated humidifier is then reviewed. A dry, bloody nose or sinus pain may signal inadequate humidity is being provided. Nasal congestion or a runny nose can be the body's attempt to compensate for dryness by flushing fluid to the area. Waking during the night after a few hours and removing the mask can also be due to congestion starting to develop. A gradual increase in humidity can eliminate these symptoms. CPAP units have various humidity ranges and the patient is encouraged to adjust his setting to find his own comfort level. During colder months, a high setting will usually create condensation in the tubing and we advise patients to place the CPAP unit on the floor so that any water can drain back into the chamber.

One of the biggest challenges with CPAP is obtaining a good mask seal for a patient who has a high pressure. We stock many masks and the patient is given the opportunity to try as many as he likes in order to find the best mask for him. With every mask, he has 30 days to exchange it for a different option.

Some people are unable to tolerate CPAP and after a strong attempt by the patient, our Respiratory Therapists may suggest AutoBIPAP, which automatically adjusts the inspiratory and expiratory pressures to the patient’s needs. When the patient is awake and not obstructing, the pressure will be minimal, but while sleeping and obstructing, it will deliver a higher pressures required to open the airway. AutoBIPAP will only be covered by insurance companies if the client fails at the use of CPAP.

Most important in the CPAP process is encouraging our patients to call us with any issues. Our follow-up care plan consists of frequent calls by our Respiratory Therapists to monitor patient progress and we encourage patients to call us if any problems arise.

You may have heard that Congress has changed the way Medicare determines who can and can’t furnish certain durable medical equipment and supplies. This new program is known as Competitive Bidding. It's already in place in nine metropolitan areas across the United States and will be implemented in the Buffalo-Niagara metropolitan area in July 2013.

Traditionally, Medicare has contracted with multiple home medical equipment (HME) providers throughout the country. However, the Competitive Bidding program will decrease the number of providers available to supply equipment and services. After July 1, 2013, only suppliers that are awarded a contract can provide equipment and supplies to people with Medicare in the Buffalo-Niagara area.

Pro2 has submitted a bid to become a Medicare contract supplier in the Buffalo-Niagara metropolitan area. Contracts for the Buffalo-Niagara area will not be awarded until the spring of 2013.

Competitive Bidding will affect you as a Medicare recipient in several ways:

-You may be required to change providers if your current provider is not awarded a contract.
-You may be required to use multiple suppliers to obtain the different products or equipment you need.

For more information on how you may be affected by this program, please visit peopleforqualitycare.org.

If you or someone you know suffers from COPD (chronic obstructive pulmonary disease), then read on.

The World Health Organization shows that death due to lung disease is currently the leading killer among people, topping cancer, heart disease, and even stroke (this is when all lung diseases such as COPD, tuberculosis, lung cancer, and lower respiratory infections are taken into account). And what's more, most people lack the understanding of how to manage lung disease.

A study published in June showed patients with COPD who suffered fatigue were more than 10 times likely to be hospitalized than COPD patients who didn't report fatigue.

The study, completed in Australia, followed 100 consecutive COPD patients over the course of roughly two years. Those patients who reported fatigue showed a 10-fold increase in the risk of being hospitalized compared to patients who didn't report fatigue in the same time period.

Research has also indicated that patients who have COPD are unaware that moderate exercise, like swimming, can actually help improve symptoms such as breathlessness.

June 27th was World Spirometry Day. A simple test such as a spirometry done at your physician's office is a great indicator of lung function and can help you better manage your own health. And yet most patients have never had a spirometry done. If you have COPD or even asthma, talk to your doctor about scheduling a spirometry. And also be sure to have a candid discussion about exercise and how it could help moderate your symptoms.