Official process for RAD (CPAP)

[leejgbt]

This is from Medicare's LCD. I am posting it to show how convoluted the rules to bill these things really are. Keep in mind that most major insurance companies follow Medicare's lead so these rules apply to most insurance companies also. Let me know if you have questions :

INITIAL COVERAGE:
A single level continuous positive airway pressure (CPAP) device (E0601) is covered for the treatment of
obstructive sleep apnea (OSA) if criteria A - C are met:
A. The patient has a face-to-face clinical evaluation by the treating physician prior to the sleep test to
assess the patient for obstructive sleep apnea.
B. The patient has a Medicare-covered sleep test that meets either of the following criteria (1 or 2):
1. 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,
2. 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:
a. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or,
b. Hypertension, ischemic heart disease, or history of stroke.
C. The patient and/or their caregiver has received instruction from the supplier of the CPAP device and
accessories in the proper use and care of the equipment.
If a claim for a CPAP (E0601) is submitted and all of the criteria above have not been met, it will be
denied as not medically necessary.
Apnea is defined as the cessation of airflow for at least 10 seconds.
Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds associated with at least
a 30% reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a
4% decrease in oxygen saturation.
The apnea-hypopnea index (AHI) is defined as the average number of episodes of apnea and hypopnea
per hour of sleep without the use of a positive airway pressure device.
The respiratory disturbance index (RDI) is defined as the average number of apneas plus hypopneas per
hour of recording without the use of a positive airway pressure device.
If the AHI or RDI is calculated based on less than 2 hours of sleep or recorded time, the total number of
recorded events used to calculate the AHI or RDI (respectively) must be at least the number of events
that would have been required in a 2 hour period (i.e., must reach 30 events without symptoms or 10
events with symptoms).
Respiratory Assist Devices (RAD)
A RAD without backup rate (E0470) is covered for those patients with OSA who meet criteria A-C
above, in addition to criterion D
D. A single level (E0601) positive airway pressure device has been tried and proven ineffective based on a
therapeutic trial conducted in either a facility or in a home setting.
If E0470 is billed and criterion D is not met, payment will be based on the allowance for the least costly
medically appropriate alternative, E0601.
A RAD with backup rate (E0471) is not medically necessary if the primary diagnosis is OSA; therefore, if
E0471 is billed with a diagnosis of OSA, the following payment rules apply:
1. If criteria A - D above are met, payment will be based on the allowance for the least costly medically
appropriate alternative, E0470; or,
2. If criteria A-C above are met but not criterion D, payment will be based on the allowance for the least
costly medically appropriate alternative, E0601.
If a CPAP device is tried and found ineffective during the initial 3 month home trial, substitution of a RAD
does not require a new initial face-to-face clinical evaluation or a new sleep test.
If a CPAP device has been used for more than 3 months and the patient is switched to a RAD, a new initial face
-to-face clinical evaluation is required, but a new sleep test is not required. A new 3 month trial would begin
for use of the RAD.
Coverage, coding and documentation requirements for the use of RADs for diagnoses other than OSA are
addressed in the RAD policy.
Sleep Tests
Coverage and Payment rules for sleep tests may be found in the local coverage determinations (LCDs) for the
applicable Medicare Part A or Part B contractor. There may be differences between those LCDs and the DME
MAC LCD. For the purposes of coverage of PAP therapy, the DME MAC coverage, coding and payment rules
take precedence.
Coverage of a PAP device for the treatment of OSA is limited to claims where the diagnosis of OSA is based
upon a Medicare-covered sleep test (Type I, II, III, or IV. A Medicare-covered sleep test must be either a
polysomnogram performed in a facility-based laboratory (Type I study) or a home sleep test (HST) (Types II,
III, or IV). The test must be ordered by the beneficiary’s treating physician and conducted by an entity that
qualifies as a Medicare provider of sleep tests and is in compliance with all applicable state regulatory
requirements.
A Type I sleep test is the continuous and simultaneous monitoring and recording of various physiological and
pathophysiological parameters of sleep with physician review, interpretation, and report. It is facility-based and
must include sleep staging, which is defined to include a 1-4 lead electroencephalogram (EEG), electrooculogram
(EOG), submental electromyogram (EMG) and electrocardiogram (ECG). It must also include at
least the following additional parameters of sleep: airflow, respiratory effort, and oxygen saturation by
oximetry. It may be performed as either a whole night study for diagnosis only or as a split night study to
diagnose and initially evaluate treatment.

Now if you wonder why DMEs ask a lot of apparently stupid questions, they are trying to comply with these regulations to get paid.

[rested gal]

I understood every line of that, and I'm not a DME or anything at all in the health care field. I just happen to have made a crazy hobby out of trying to understand SDB (sleep disordered breathing) and the various machines to treat it. Have read a lot about it. Haven't stayed at a Holiday Inn Express lately, though, so I may be getting behind...

People who are getting PAID to handle sleep studies and people who are getting PAID to provide DME (durable medical equipment) for the treatment of sleep disordered breathing should not have any problem learning the ins and outs of the medicare requirements you posted.

"Sleep doctors" who get PAID to evaluate sleep studies and make treatment recommendations should not have any problem determining what type of initial treatment is required, and they should have a good idea what it would take to get the patient a RAD (bi-level or SV machine, as opposed to a straight CPAP machine) covered right from the get-go.

I'm confused. In order for the DME to comply with the regulations and get paid, what are a few examples of "apparently stupid questions" the DME might ask patients? I'd have thought everything the DME needed to know for that would be available to the DME in the sleep study report and physician's Rx, no?

[ScrappinMom]

I'd have thought everything the DME needed to know for that would be available to the DME in the sleep study report and physician's Rx, no?

Exactly!!! The regulations are really not that complicated. And, the reason for even needing them is because DMEs have historically been the most fraudulent provider in the Medicare program.

[leejgbt]

Scrappinmom wrote:

Exactly!!! The regulations are really not that complicated. And, the reason for even needing them is because DMEs have historically been the most fraudulent provider in the Medicare program.

Where in the world do you get your info????? The most fradulent provider in the Medicare program historically is.......HOSPITALS! Look it up. DME accounts for less than 5% of the entire Medicare budget. Providing equipment in the patient's home is by far the least expensive use of insurance dollars and has the greatest positive outcomes. For DMEPOS, billing fraud accounts for less than 6% of what is spent (and most of that could be argued is billing errors due to the complexity of the billing regulation). While this is still too high lets aim blame at where it belongs. Medicare gave unscrupulous providers their provider numbers without any type of licensing or accreditation until October of this year. Yes 2009. The DME industry has been begging for mandatory accreditation for over 10 years. Until last year Medicare spent over 40% of its DME budget on administrative expenses but not one penny of this was on fraud prevention. In Florida providers did not even have to have a real location. All it took was an application to Medicare to become a provider.

Add to this that sleep therapy is just now starting to be understood and then it should not be surprising that many of the people on this site have had bad experiences with DME companies. Most DME companies are trying to do it right but the learning curve to accomplish this is steep and long. Add the fraudulant providers on top of this and you have the situation you have today.

Second, read what these regulations really mean. What happens if you are compliant 3.9 hours 70% of the 30 days? How do you determine 4 hours per night? Does it have to be 4 continuous hours? What if you get up and do not go back to sleep for 45 minutes, do you start over? If the sleep physician misinterprets leaks in the mask and increases the pressure, can you correct this? What if the sleep physician does not do a follow up, will the DME get reimbursed? What happens if you have the flu in the middle of the 90 day trial and you do not get compliance, what happens? If the patient has co-morbidities (like I do) and does not reach the 4 hours per night threshhold until it is too late how do I get my insurance to pay or will they? Six months down the line is the DME provider still required to gauge compliance? What happens if the DME provider does not? What do you do if the sleep doctor orders CPAP and the AHI is 3? If you recommend the patient does not need sleep therapy you risk losing a referral source, or in some cases the only referral source. If you set the equipment up will the patient benefit? What do you do with the patient that has an AHI of 88 but is non-compliant and now the insurance will not pay and the patient wants to return the equipment but the physician still wants the patient to have the equipment? If any of the rules are not followed by the physician or the patient who does not get paid? (The DME provider)

Questions that I have read on this site that mean the DME provider is not up on the rules or are misintrepreting the rules:

Your insurance will not pay for "auto". If your insurance pays for HCPCS codes E0601, E0470, E0471, E0472 then it will pay for "auto".
The provider was not in network so the insurance will not pay. Not true. You may have a separate deductible and co-payment but the insurance will pay as long as it is a covered item.
You must have a current sleep study. Not true. You only need a qualifying sleep study.
You can only have a mask every six months. Not true. You can have a mask every 3 months with Medicare but most insurances and Medicare allow for exceptions if documented and ordered by the physician. Most say six months because the manufacturers include the headgear with the mask which can be replaced only every six months.

I have read some pretty horrific stories about terrible DME providers, sleep physicians and sleep labs. As I had a very difficult time using my CPAP but now love the benefits I am dedicated to helping anyone who has problems. Most of the advise I read is pretty good. I am not a big fan of using on-line companies like CPAP.COM out the gate as having a qualified RT to resolve any issues and fit the mask properly will greatly increase the chances of a positive outcome versus taking a chance on getting it right. But, I will assist anyone who asks and give them the pros and cons of any strategy they choose. I will also let anyone know if the DME provider is telling them proper processes.

[ScrappinMom]

leejgbt.
Wow, I sure set you off, didn't I.

[cinco777]

leejgbt wrote

I am not a big fan of using on-line companies like CPAP.COM out the gate as having a qualified RT to resolve any issues and fit the mask properly will greatly increase the chances of a positive outcome versus taking a chance on getting it right.

My personal DME experiences and the DME experiences of the vast majority of the members of this forum suggest that finding a qualified RT is running a close second to finding a unicorn in the back yard. Luckily, we found this forum and, after learning "the ropes" from the knowledgeable, experienced, and helpful XPAP users on this forum, took control of our Sleep Therapy and succeeded.

To avoid the frustration, incompetence, apathy, run-arounds, lies, deceit, greed, ... that we have experienced with the B&M DMEs, we now buy online (CPAP.com and others) and get our assistance from other users on this forum, who, unlike the DMEs, know what they are talking about and share their valuable and helpful knowledge and recommendations.

[SleepyT]

I understood every line of that, and I'm not a DME or anything at all in the health care field. I just happen to have made a crazy hobby out of trying to understand SDB (sleep disordered breathing) and the various machines to treat it. Have read a lot about it. Haven't stayed at a Holiday Inn Express lately, though, so I may be getting behind...

[Kiralynx]

Now if you wonder why DMEs ask a lot of apparently stupid questions, they are trying to comply with these regulations to get paid.

Could you please give me examples of the "apparently stupid questions" which DMEs have to ask in order to comply with the regulations?

I am not a big fan of using on-line companies like CPAP.COM out the gate as having a qualified RT to resolve any issues and fit the mask properly will greatly increase the chances of a positive outcome versus taking a chance on getting it right.

Hmm. My B&M DME made no effort to fit a mask: they didn't need to because I had already found a mask which worked for me, thanks to what I learned in the Forum. I asked the mask specialist at the sleep center for help before my titration. The DME just ordered what I asked for.

Now, in fairness, I needed a Bipap, as determined by my titration. The RT at the B&M did get me an excellent one. But only after I told her that if it was not fully data capable, I would reject it, and she could order another one. (Something I learned on this Forum.)

Fitting? Oh, when I went out to pick up my machine, the RT did have me try it on, so she could be sure I knew how... but she had no bed for me to lie on, nor anything set up for testing the mask under pressure, so as far as that went, I was better off picking a mask by the pictures on-line, because the B&M DME had no other masks in stock for me to try if the one they'd ordered didn't work. All masks must be ordered -- and it takes 5-7 working days to get one in, then a drive across town to pick the darn thing up, versus CPAP.COM delivering it right to my door.

Resolving issues? Geeze. I had to call her the next morning and demand to know how to turn off the bleeping alarms which were left on, and which kept me from doing a complete night from the start.

I bought (from CPAP.COM) the card reader, the cards, and the software. I troubleshot the issues, from determining that my leak rate was too high, and addressing the need for a chin strap by inventing my own since none of the commercial ones worked for me, and including the fact that the machine wasn't set correctly for me. I then called the RT and told her, "These are my conclusions, based on this information." She agreed, and did get a new prescription issued. She then walked me through changing the pressures on my machine, something I could have done for myself if the directions had been in the box.

"My" RT has never been near my house -- and is unlikely to come, probably because she's afraid of my dogs. Any "support" has been done over the phone. Any "reports" have been sent via email. The B&M DME doesn't even want to talk to me to see how things are going: they've set up an automated phone call thing so they don't have to interact in person with me.

So, I'm just curious. What is it a brick-and-mortar DME is supposedly capable of providing that a company like CPAP.COM can't?

So far, the B&M hasn't shown me anything they do better. Well, no, I take that back -- they're excellent at billing my insurance, which CPAP.COM does not do. But that's the ONLY thing they do better.

[tonycog]

I am not a big fan of using on-line companies like CPAP.COM out the gate as having a qualified RT to resolve any issues and fit the mask properly will greatly increase the chances of a positive outcome versus taking a chance on getting it right. But, I will assist anyone who asks and give them the pros and cons of any strategy they choose. I will also let anyone know if the DME provider is telling them proper processes.

My local DME provider and a second, different local DME provider, the 2 biggest in the area, both have "qualified RT to resolve issues and fit the mask properly". Both told me "We're sorry. We don't know how to get your mask to not leak. You'll just need to talk with your doctor." The doctor, of course, has never spent a night wearing a mask. He can diagnose sleep disorders. I even think he is a good and concerned doc. However, he knows nothing about fitting a mask.

When my wife gets her sleep study I am assuming she will be diagnosed with OSA. I will not be buying locally from a "qualified RT blah blah blah". The only ones I have personally met are only qualified because they were able to pass a test. I now have more qualifications to help my wife fit her mask. My test did not provide me with any certification, but I know I'll be more helpful to my wife.

Tony

[leejgbt]

Maybe I was very lucky. I had an RT who used a fitting room with a reclining chair to fit my mask. My nose was measured and based on the measurement several masks were suggested which I got to try. I was asked to lay on each side and on my back. The RT then asked me which mask I preferred. I was completely happy with the mask. I am baffled by the person who said the RT could not find a mask that did not leak. I called the RT who fitted me and she used words like "lazy", "untrained" and "limited selection" to describe the other RT.

I have asthma and so I have issues with masks that leak into my eyes. I used an ultra mirage medium and it worked great. What I did not realize is that as the cushion wears and when I tighten the headgear I was contributing to mask leaks. I have since switched to the Swift LT and love it! No chance, even with leaks, of air blowing into my eyes. I have learned to change the cushions as prescribed and then no leaks occur.

I am still amazed that people find masks that fit, given the vast differences in sizes and shapes, without a formal mask fitting. More power to them. BTW I order replacement cushions from CPAP.com due to pricing. I also have billing experience so have no trouble getting my insurance to pay.

[tonycog]

I am baffled by the person who said the RT could not find a mask that did not leak. I called the RT who fitted me and she used words like "lazy", "untrained" and "limited selection" to describe the other RT.

I was baffled as well. I had 2 different RT's tell me this. Neither suggested that lying on my side vs. on my back might help. Neither showed me the importance of making sure that the head gear was centered. Neither offered any help or advice for my sore nose bridge. Both were very quick to determine if my insurance would pay.

As for "limited selection", for one of the DME providers, yes. I asked specifically about a Ultra Mirage FF, Quattro and Liberty. I was told that they did not carry Resmed masks since they are more expensive. Since at this particular store any mask is billed out at $200 for mask and $45 for head gear, we know who is really concerned about higher price. I would need to special order these, pre-paid, of course, at $245 each.

"Lazy" and "untrained" are perfect adjectives.

Tony

[mattman]

I'd have thought everything the DME needed to know for that would be available to the DME in the sleep study report and physician's Rx, no?

Just for what it's worth - about half the time we would get prescriptions for cpaps without a single other piece of information. We generally considered it a victory to even get a summary of a sleep study with a prescription (Most insurance companies won't accept a summary - you have to have the full study on file). It was a constant battle to get all the information needed to even start trying to figure out if someone would qualify and Gawd help you if the diagnosis was something other than straight OSA since the documentation goes up exponentially.

Fun fact: a lot of insurers still require a dx of 780.57 (OSA) to qualify. The standard sleep disorders/sleep disordered breathing (780.50) is specifically denied for CPAP treatment. So every Rx that comes over with 780.50 (about 20%) you have to start calling all over town trying to find a chart or note somewhere that specifically says Obstructive Sleep Apnea. Good times.