With the recent extension of the public health emergency (PHE) and CMS’s announcement to restart audit activity, suppliers continue to struggle with the vague distinctions between baseline medical necessity and permissible deficiencies during the PHE under the relaxed documentation standards. Last week we discussed specifics related to oxygen setups; this week we zero in on PAP and RAD.
PAP
The baseline for PAP therapy starts with evidence of sleep-disordered breathing. Practitioners should document a physical exam that measures neck circumference and body mass index (BMI). The medical record should also reference patient symptoms indicative of obstructive sleep apnea (OSA), such as:
For continued use beyond the trial period, suppliers must document timely compliance using downloads from the machine and coordinate telehealth visits with the practitioner to document objective and subjective evidence of improvement.
Potentially Permissible Deficiencies for PAP Setups
Under the relaxed guidelines, patients will not necessarily have a traditional sleep study or documented apnea hypopnea index.
RAD
The baseline for RAD therapy generally starts with symptoms characteristic of sleep-associated hypoventilation, such as:
If routinely required testing is not feasible during the PHE, we advise suppliers to ensure the medical record documents an estimation on how and when the practitioner will coordinate further testing.
For continued use beyond the trial period, the medical record must document:
Under the relaxed guidelines, patients will not necessarily have lab-performed test results to confirm a suspected diagnosis per the LCD requirements. Practitioners may not be able to perform many of the routine tests required in the LCD that measure arterial blood gas, forced vital capacity, forced expired volume, or carbon dioxide retention.
Suppliers must monitor patients carefully and discontinue billing if the underlying condition improves. If the condition endures, suppliers must obtain objective evidence using baseline medical necessity requirements before the PHE ends.
PAP
The baseline for PAP therapy starts with evidence of sleep-disordered breathing. Practitioners should document a physical exam that measures neck circumference and body mass index (BMI). The medical record should also reference patient symptoms indicative of obstructive sleep apnea (OSA), such as:
- Snoring.
- Daytime sleepiness.
- Witnessed apneas.
- Choking or gasping during sleep.
- Morning headaches.
- Hygiene inventory indicators (e.g. Epworth Sleepiness Scale).
For continued use beyond the trial period, suppliers must document timely compliance using downloads from the machine and coordinate telehealth visits with the practitioner to document objective and subjective evidence of improvement.
Potentially Permissible Deficiencies for PAP Setups
Under the relaxed guidelines, patients will not necessarily have a traditional sleep study or documented apnea hypopnea index.
RAD
The baseline for RAD therapy generally starts with symptoms characteristic of sleep-associated hypoventilation, such as:
- Daytime hypersomnolence.
- Excessive fatigue.
- Morning headaches.
- Cognitive dysfunction.
- Dyspnea.
If routinely required testing is not feasible during the PHE, we advise suppliers to ensure the medical record documents an estimation on how and when the practitioner will coordinate further testing.
For continued use beyond the trial period, the medical record must document:
- Compliant usage of the equipment using downloads from the machine.
- Subjective evidence of improvement (via telehealth visits when in-person encounters are not feasible).
Under the relaxed guidelines, patients will not necessarily have lab-performed test results to confirm a suspected diagnosis per the LCD requirements. Practitioners may not be able to perform many of the routine tests required in the LCD that measure arterial blood gas, forced vital capacity, forced expired volume, or carbon dioxide retention.
Suppliers must monitor patients carefully and discontinue billing if the underlying condition improves. If the condition endures, suppliers must obtain objective evidence using baseline medical necessity requirements before the PHE ends.
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