On May 16, 2019, the MACs published instructions that prohibits payment for PAP equipment and supplies between an unsuccessful initial trial and a clinical re-evaluation that documents therapeutic benefit.
What Does This Mean?
Every PAP failure means lost Medicare revenue until the supplier can fully document compliance. According to the bulletin, after the initial trial, suppliers can only bill for service dates that follow a compliant re-evaluation.
In these circumstances, suppliers must complete the following five steps to resume payment:
Claims with dates of service beyond the initial trial and before the date the physician completes the final clinical re-evaluation remain unpayable. During any interim period, the supplier should execute an ABN and collect from the beneficiary.
Does This Clarification Affect the RAD Policy?
No. The clarification only applies to beneficiaries with obstructive sleep apnea under the PAP policy. The Respiratory Assist Device (RAD) LCD addresses other medical conditions like central sleep apnea, severe COPD, and complex sleep apnea. The RAD LCD is not governed by the same national coverage determination that spurred this clarification.
Is There Anything We Can Do?
We are actively developing our understanding of the surrounding facts to inform our next move. MiraVista is searching for a viable alternative to the MAC’s interpretation. A few ideas we are exploring include:
In the interim, suppliers should immediately educate staff to cease billing Medicare with a KX modifier for rentals and accessories during repeat trial periods.
SOURCE LINKS
https://cgsmedicare.com/jb/pubs/news/2019/05/cope12486.html
What Does This Mean?
Every PAP failure means lost Medicare revenue until the supplier can fully document compliance. According to the bulletin, after the initial trial, suppliers can only bill for service dates that follow a compliant re-evaluation.
In these circumstances, suppliers must complete the following five steps to resume payment:
- Secure face-to-face clinical re-evaluation by the treating practitioner to determine the etiology of the failure to respond to PAP therapy.
- Repeat sleep test in a facility-based setting (Type 1 study). This may be a repeat diagnostic, titration or split-night study.
- Document in-home use of a PAP device for 31-90 days.
- Document adherence through use of the PAP ≥4 hours per night on 70% of nights during a consecutive thirty (30) day period within the 90 day repeat trial.
- Secure a face-to-face clinical re-evaluation with the treating practitioner to document improved symptoms of obstructive sleep apnea and objective evidence of adherence.
Claims with dates of service beyond the initial trial and before the date the physician completes the final clinical re-evaluation remain unpayable. During any interim period, the supplier should execute an ABN and collect from the beneficiary.
Does This Clarification Affect the RAD Policy?
No. The clarification only applies to beneficiaries with obstructive sleep apnea under the PAP policy. The Respiratory Assist Device (RAD) LCD addresses other medical conditions like central sleep apnea, severe COPD, and complex sleep apnea. The RAD LCD is not governed by the same national coverage determination that spurred this clarification.
Is There Anything We Can Do?
We are actively developing our understanding of the surrounding facts to inform our next move. MiraVista is searching for a viable alternative to the MAC’s interpretation. A few ideas we are exploring include:
- Can we convince CMS that patients benefit from therapeutic intervention, even if they have yet to achieve “adherence” (possibly using a titration study that documents reduction in apneas and hypopneas)?
- If CMS will not waiver and the NCD language is problematic, should the industry pursue an NCD reconsideration?
In the interim, suppliers should immediately educate staff to cease billing Medicare with a KX modifier for rentals and accessories during repeat trial periods.
SOURCE LINKS
https://cgsmedicare.com/jb/pubs/news/2019/05/cope12486.html
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