Switched from CPAP to Auto CPAP - question

I can't see how resetting the machine would reset the card. That makes no sense at all. 4cM also makes no sense. I would suffocate at 4cM. I agree to set the lowest setting a little below your titrated pressure. If you are titrated over 10cM, why suffer through the ramp-up every night? I also am not a fan for 20cM max unless you know you have no leak problems with your mask. How do you know this? You buy the card reader and download your data and the software backs up your data on your PC.

can you even erase the card without a card reader????

The companies have shown that an auto set at 4-20 will frequently reach the same 90% recommended pressure as a sleep tech in a PSG, and they try to sell autos as a simple, not hassle solution. Some professionals buy that spiel. They don't know how the machines really work, they don't know that sleeping with the auto is different from getting diagnosed by it.

The doctor may know a lot about sleep, a lot about the many kinds of problems that may disrupt sleep, a lot about differential diagnosis. And nothing about the way the various machine function.

Tell your doctor how unhappy you were with the lower pressure, ask him why his switched you to an auto - and the try to explain why you want a higher minimal pressure.

O.

I'd agree with those assumptions, Jim. Nice job you did, outlining them so clearly.

JimW203 wrote:Questions:
1) Can you switch what is recorded on the card from "Compliance" to complete data at will?
2) Is that switch detectable in the compliance data record?

I think the answer to 1) is "no" -- which renders 2) moot.

Assuming it's a machine capable of recording more data than just Compliance (hours of use) there's no way in the card, the software, or the machine to simply switch recording back and forth between just Compliance data vs Detailed data. The Smart Card is always going to record the full amount of data the machine is capable of recording in the first place and putting on the card. Barring any glitches, of course.

You already know this next part, Jim. I'm continuing for the benefit of new readers:

After a download is done, there's a way in the software to choose whichever level of detail you want to view:
Summary (which is just "compliance" and is probably the only report a DME bothers looking at)
Trend (about the same)
Full Details

But there's no way to change what amount of data the machine records onto the Smart Card.

If a person uses the Encore Viewer software to download the Smart Card from a Respironics machine, Encore Viewer will never erase the card. All data will remain intact on the card no matter how many times the user downloads the card. There will be no indication on the card itself that anyone has ever done a download. There's no danger of accidentally erasing the data if Encore Viewer software is used.

However, if a person uses the software the DMEs use (Encore Pro software instead of Encore Viewer software) Encore Pro will automatically erase the card after each download, UNLESS a setting in Encore Pro is changed before doing the first download using Encore Pro.
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ozij wrote:The companies have shown that an auto set at 4-20 will frequently reach the same 90% recommended pressure as a sleep tech in a PSG, and they try to sell autos as a simple, not hassle solution. Some professionals buy that spiel. They don't know how the machines really work, they don't know that sleeping with the auto is different from getting diagnosed by it.

The doctor may know a lot about sleep, a lot about the many kinds of problems that may disrupt sleep, a lot about differential diagnosis. And nothing about the way the various machine function.

Tell your doctor how unhappy you were with the lower pressure, ask him why his switched you to an auto - and the try to explain why you want a higher minimal pressure.

O.

Well said, ozij!!

Only thing -- I'd be very careful how I asked (if I asked at all...I wouldn't look a gift horse in the mouth! ) "Why did you switch me to an auto?" If the doctor got annoyed at a well informed patient asking questions about a machine he really doesn't understand all that well, he might say, "That was for diagnostics purposes. I'm switching you now to a CPAP machine."

JoyD. wrote: She reminded me that if I want Medicare to pay for all my stuff (which I do!!!), that I'd better not get into the provider settings again.

Let me assure you that this is not true. I have medicare as my primary insurance. The DME knew early on in my rental period that I knew how to enter the set up menus and that I had changed my pressure. Medicare has continued to pay for the rental and the machine will be mine in a couple months. Medicare does not base its payments on what your settings are or who sets them, it bases those payments on whether you need the machine and whether you use it. That's it. They just want to know that you need it and you do use it, that's all they care about and they will pay so please do not be worried about this nonsense your DME is telling you!

What she meant by that is that when I took my old machine in (it was all zeroed out to do daily readings) . . . and she took the data card back to read the compliance data for Medicare, no data was on it! It said "Error" and all the data was gone. She did retrieve the accumulated data for the blower, from the machine itself. But nothing was on the card to print out for Medicare. Medicare now requires a printout to prove "daily compliance" (over 4 hours of therapy daily minimum for every day). The RT is going to cover for me by blaming it on a corrupted card, but we know better. When I zeroed out the therapy usage daily after writing down the daily AHI, leak, and hours of therapy data . . . I believed that it wouldn't erase the data on my card . . . but this turned out not to be true.

I believe she is either really incompetent and messed up the data herself, or the computer had a problem or she is lying to you. Resetting the screens cannot erase the card. In any case, it doesn't matter for Medicare. Medicare has been paying for these machines since before there were data cards in them. You only need a doctor's order saying it is medically necessary and then you need to say that you are using it. That's it and Medicare will pay. Please call Medicare to verify this, do not take the DME's word for it. It's really crappy that they are telling you this.

Also, I have only had to provide card downloads twice very early on in the Medicare rental. So far they have not asked me for another download. Please do not be afraid to get the therapy you need, Medicare will pay for it no matter what you do as long as you are using it and you need it. I also think you should ask your doctor directly why you need to be switched to an auto pap if the machine you had is working fine for you.

In light of the newest Medicare requirements, I can understand why a DME would be concerned if the Smart Card has no data on it:

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akcpapguy is a very experienced DME who has posted very helpful info before. If he's correct about some of the new Medicare rules that perhaps weren't in effect at the time you started cpap, nobody, JoyD.'s DME may have good reason to worry about proving compliance with a Smart Card that has no data on it:

akcpapguy wrote:2. Medicare requires you to have a followup appointment with you treating physician between the 31st and 91st day on therapy. The physician must document that he has seen and reviewed your previously mentioned compliance data.

In addition, as I understand it, in the face-to-face meeting with the doctor, the doctor also has to document that the patient is not only meeting compliance requirements, but is also benefitting from the treatment.

nobody wrote:Medicare has been paying for these machines since before there were data cards in them. You only need a doctor's order saying it is medically necessary and then you need to say that you are using it. That's it and Medicare will pay.

I don't know if that's still the case with the recent changes in Medicare's reimbursement rules for "cpap" -- tightening up their requirements for "cpap" reimbursement. Nowadays, if I understand it right, I think it may take more documentation -- objective proof, as in a download from the machine -- signed by the doctor. Not just a statement by the doc, DME, or the patient, that the machine is being used. Of course, how stringently that might be enforced could depend on the particular Medicare region a person is in.

nobody wrote:Please call Medicare to verify this, do not take the DME's word for it.

Good advice! I'd add, nor anyone's word for it..not mine, not nobody's, not akcpapguy's. And maybe not even the person who answers the Medicare phone -- some of them may be as confused about interpreting the new Medicare rules as anyone!

JoyD.'s DME girl sounds like one who is really working hard to be helpful and does appreciate Joy educating herself and being so pro-active about treatment.

I've searched on Medicare.gov and could find nothing about new rules or what they are, do you know where that can be verified (from Medicare)? I've only heard of new rules regarding oxygen, none regarding CPAP. There is nothing in the 2009 handbook about it either. The handbook, which is sent to all Medicare recipients and is available on the website*, says nothing about different rules for different areas. The 2009 handbook references this publication:
http://www.medicare.gov/Publications/Pubs/pdf/11045.pdf in which I could find none of the things you or this other guy suggests. So if these things can be verified, I would like to see them (from Medicare), since it has not been my experience at all.

*http://www.medicare.gov/Library/PDFNavi ... ubID=10050

rested gal wrote:I'd agree with those assumptions, Jim. Nice job you did, outlining them so clearly.

JimW203 wrote:Questions:
1) Can you switch what is recorded on the card from "Compliance" to complete data at will?
2) Is that switch detectable in the compliance data record?

I think the answer to 1) is "no" -- which renders 2) moot.

If a person uses the Encore Viewer software to download the Smart Card from a Respironics machine, Encore Viewer will never erase the card. All data will remain intact on the card no matter how many times the user downloads the card. There will be no indication on the card itself that anyone has ever done a download. There's no danger of accidentally erasing the data if Encore Viewer software is used.

However, if a person uses the software the Dames use (Encore Pro software instead of Encore Viewer software) Encore Pro will automatically erase the card after each download, UNLESS a setting in Encore Pro is changed before doing the first download using Encore Pro.
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RG,

Thanks for the clarification. This raises additional questions:
1) Is Encore Viewer capable of being used to back-up the data from the card onto a computer's HD?
2) Is the data presented to the card cumulative? That is - the user takes the card to the DME, the DME reads it, Encore Pro erases it. Does the card, when reinserted into the machine, start from where it last recorded with all data forward untill removed, or does it record all previous data from day one?

If 1) is yes, then would it not be simple for the user to download a B/U of the card onto the HD for further analysis/review? The answer to 2) would merely establish the B/U procedure.

Of course, all of this is dependent upon the DME's procedure in reading the card. My brief experience with DME and RTs at doctors' offices leads me to expect them to do the minimum needed for their reporting requirements. I suspect intellectual curiosity regarding treatment efficacy is low in the hiearchy of job requirements.

JimW203

JimW, those are all good questions.

Or I guess they are, 'cause those questions have moved beyond what little I'm familiar with when it comes to techie stuff.

I hope the more computer-savvy Encore Pro / Encore Viewer users will weigh in.

I don't know the answers, but will be very interested to read what others say.

I think there's a free Smart Card back-up utility that a cpaptalk member developed. I haven't used it and don't know if the program even has any relevance to the questions you're asking now. Just, well...felt like mentioning it so I could pepper this post with a link! LOL!!!
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nobody wrote:I've searched on Medicare.gov and could find nothing about new rules or what they are, do you know where that can be verified (from Medicare)?

This may not be exactly what you want, but I found it on Resmed's website. My doctor and DME have both told me exactly the same info.

http://www.resmed.com/en-us/dealers/doc ... de-r21.pdf The following is on page 12.

Continued coverage of a PAP device (E0470 or E0601) beyond the first three months of therapy requires that, no sooner than the 31st day but no later than the 91st day after initiating therapy, the treating physician must conduct a clinical re-evaluation and document that the beneficiary is benefiting from PAP therapy.

For PAP devices with initial dates of service on or after November 1, 2008, documentation of clinical benefit is demonstrated by:

1. Face to face clinical re-evaluation by the treating physician with documentation that symptoms of obstructive apnea are improved; and,

2. Objective evidence of adherence to use of the PAP device reviewed by the treating physician.

There is more detail about what compliance means, but objective means the print out or some other proof than "I say so." I am right in the middle of this period myself, so it is of interest to me. I have been tracking my symptoms, and how they respond to therapy, and which changes (mask, pressure) make things better or worse, and will take that in with me for my appointment with my treating doctor. From what I understand, that means the doctor that diagnosed the apnea and prescribed the treatment, not my regular doctor.

Thanks riverdreamer! I guess I am not subject to that since I got my machine before Nov 1. I have done all that anyway. I've taken printouts of my card downloads to my doctor. I wonder how they define a few of those things. I wonder if under the new rules they would have stopped paying for mine because I ended up having another sleep disorder and so my symptoms were not all that improved until I got medication in addition to the CPAP.

Anyway, it still doesn't explain why the OP is told she can't go into the setup menus or Medicare won't pay. Even if some how the card was erased, there are still some things on the machine that can't be reset like blower hours and there's also a compliance check number on there that can't be reset. So even with the card data missing, there are other things they could fall back on to objectively document compliance.

I think just blower hours are not enough, because the criteria go on to detail hours per night, percent of nights per week, etc. In other words, they want a breakdown of how much of the possible time therapy is used, in addition to whether you are improving.

Assuming they give her a new machine, it should have been blower hours 0 at the start. That together with the current blower hours would be enough information to find an average for hours per night, percent nights per week, etc. I realize that is not an exact number for exact nights, but that is what they would have to do anyway if the card is corrupted for some reason, which seems to be the case here. I'm sure that Medicare understands that crap happens. I doubt they will cut off paying for her machine, they might require another download later, but I don't think they will stop paying. I would be very surprised. And if they did I'd encourage her to appeal it.

riverdreamer wrote:I think just blower hours are not enough, because the criteria go on to detail hours per night, percent of nights per week, etc. In other words, they want a breakdown of how much of the possible time therapy is used, in addition to whether you are improving.

Rested Gal said:

I don't know if that's still the case with the recent changes in Medicare's reimbursement rules for "cpap" -- tightening up their requirements for "cpap" reimbursement. Nowadays, if I understand it right, I think it may take more documentation -- objective proof, as in a download from the machine -- signed by the doctor. Not just a statement by the doc, DME, or the patient, that the machine is being used. Of course, how stringently that might be enforced could depend on the particular Medicare region a person is in.

It's already happened . . . I spoke with a different RT (from a DME I have used in the past) just to see what she'd say. She reported the exact thing my current RT/DME explained . . . that it is a REAL PAIN for everyone with the new Medicare requirements. Both told me that now they require a PRINTOUT to be mailed in with each report as objective proof, not just a statement from the DME. (I don't know yet what is required of the physician; I assume the same.)

I have appreciated everyone's empathy, input, and information to my question. It's so great to have this community I must say though, that I do believe I have a helpful RT & DME, but she must fulfill the physician's request and follow Medicare's rulings. Perhaps, as RG suggested, it was a corrupted card, etc. but regardless of what the RT "thought" I might have done to mess up the card, she reported it as "corrupted" with no urging from me. I believe she is genuinely worried for me that we might have a real problem with Medicare if this keeps happening, and sincerely doesn't want me to end up having a fight on my hands getting Medicare to pay. She knows first hand what a stickler it is now to fulfill all Medicare's new requirements.

I am currently reading all the medical literature that I can (studies that my doctor reads) pertaining to AutoCPAP settings, etc. I am finding some good stuff I'll share on this forum when I'm finished digesting it all. I changed my appointment with my sleep doc from March 3rd to 18th. So I'll have a lot to discuss with him intelligently. (I was a pharmaceutical representative for 20 years, so I am used to discussing the medical literature with MDs.) Also, dealing with their egos I currently have my APAP set at 11-20 and will leave it here for 11 days total; then I'm changing the setting to 4-20 for the last 11 days before my appointment (per RG's urging). I'll get a printout to take to him. He can look at the difference between the two settings.

BTW, I set my APAP at 11=20 based on Sleep Lab Titration of "13 cm H2O" that took care of ALL events, but that was w/o REM and only 2 hours sleep.)

Joy

I guess in a way I can understand it since there is fraud and waste in Medicare and they should be as efficient as possible. Just FYI, the info on the card will still show that you had the pressure set on something differently than the 4 -20. Even though it only keeps the nightly data for a week, it will track for a much longer time the hours per night (for each night), the pressure settings, humidifier setting, cflex setting, apneas, etc. I can show you some images of it if you want. I have several months worth of my own data and it does save a lot of it. Anyway, it sounds like you have a good plan of action. Let us know how it goes.