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CPAP Documentation & Guidelines
The PAP Medicare LCD applies to both a single-level continuous positive airway pressure device and a bi-level respiratory device without back-up rate when it is used in the treatment of obstructive sleep apnea (OSA). The diagnosis of OSA must be documented by either an attended facility-based polysomnogram (sleep study) or unattended home sleep test (HST) and interpreted by a qualified physician.
A single-level continuous positive pressure (CPAP) is covered if criteria A-C are met.
A. Treating physician conducted a face-to-face clinical evaluation prior to the sleep test to assess the patient for OSA. The face-to-face clinical evaluation is documented in a detailed narrative note in the patient's chart in the format the physician uses for other entries. The following elements should be included in the meidcal notes:
History:
- Signs and symptoms of sleep disordered breathing including snoring, daytime sleepiness, observed apneas, choking or gasping during sleep, morning headaches.
- Duration of symptoms.
- Validated sleep hygiene inventory such as the Epworth Sleepiness Scale.
Physical Exam:
- Focused cardiopulmonary and upper airway system evaluation
- Neck circumference
- Body mass index (BMI)
B. The patient has a Medicare covered sleep test that meets either of the following criteria:
- The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events; or
- The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of:
- Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or
- Hypertension, ischemic heart disease, or history of stroke.
[Note: The sleep test may be performed as either a whole night for diagnosis only or as a split night to diagnose and initially evaluate treatment. If the AHI or RDI is calculated based on less than 2 hours of sleep or recording time, the total number of recorded events used to calculate the AHI or RDI must be at least the number of events that would have been required in a 2-hour period.]
C. The patient and/or caregiver received instruction from the supplier of the PAP device and accessories in the proper use and care of the equipment.
Additional Criteria for BiPAP (without back-up rate)
A BiPAP device is covered for those patients with OSA who meet criteria A-C above, in addition to criterion D.
D. A single-level positive airway device has been tried and proven ineffective, based on a therapeutic trial conducted in either a facility or in a home setting.
- Interface fit and comfort was addressed and an appropriate interface has been properly fit and the beneficiary is using it without difficulty. This interface will be used with the BiPAP device; and
- Adjustments to the PAP/CPAP pressure setting were addressed. The current pressure setting of the PAP/CPAP prevents the beneficiary from tolerating the therapy and lower pressure settings of the PAP/CPAP were tried but failed to:
- Adequately control the symptoms of OSA; or
- Improve sleep quality; or
- Reduce the AHI/RDI to acceptable levels.
Continued Coverage Beyond the First 3 Months of Therapy
The treating physician's records document a clinical re-evaluation no sooner than the 31st day but no later than the 91st day after initiating therapy and documents that the beneficiary is benefiting from PAP/CPAP therapy as demonstrated by:
- Improvement in the symptoms of the OSA; and
- Objective evidence of adherence to use of the PAP/CPAP device.
- Direct download or visual inspection of usage data verifies that the beneficiary has used PAP/CPAP 4 or more hours per night on 70% of nights during a consecutive 30-day period any time during the first three months of initial usage; and
- Treating physician reviewed written report of adherence data.
The re-evaluation should be documented in a detailed narrative note in the patient's chart in the format the physician uses for other entries.
NHIC, Corp. Local Coverage Determination (LCD) for Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L11528). Retrieved July 9, 2012 from http://www.medicarenhic.com/dme/medical_review/mr_lcds/mr_lcd_current/L11528_2011-10-01_PA_2011-02.pdf
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