Medicare ups ante for CPAPs

Thursday, April 1, 2010

BALTIMORE - Just when CPAP providers thought CMS couldn't possibly impose more documentation requirements on them, the DME MACs last week began enforcing new local coverage determinations.

As of April 1, four specific coverage requirements must be documented by the physician before the provider can move a patient from a CPAP (E0601) to a bi-level machine. Previously, it was enough to show that the beneficiary tried and was unsuccessful with attempts using the CPAP device. In addition to that, physicians now must also document that:

* Multiple interface options have been tried and the current interface is most comfortable to the beneficiary; and

* The work of exhalation with the current pressure setting of the E0601 prevents the beneficiary from tolerating the therapy; and

* Lower pressure settings of the E0601 fail to adequately control the symptoms of OSA or reduce the AHI/RDI to acceptable levels.

It's another example of "good medicine, bad policy," stakeholders say.

"It's hard enough to get physicians to document things like 'hey, the patient feels better,' much less get them to document things related to pressure relief," said Kelly Riley, director of The MED Group's National Respiratory Network. "Certainly, the sleep doctors and pulmonologists understand the things related to expiratory pressure, but I'm not sure that's the case with all primary care practitioners. That's an awful lot to ask."

Another concern for providers: Many times, the patient fails on standard CPAP in the sleep lab, but the physician still must document all four requirements before the provider can put the patient on a Bi-Level.

"How do we know what happens in a sleep lab?" said Helen Kent, president of Progressive Medical in Carlsbad, Calif. "The doctor calls or the lab calls with a Bi-Level referral but then the onus is on us to find out what they did in the lab. Lots of times we get the sleep report, but it isn't thorough enough."

The policy change gave providers only about three weeks to educate physicians on the changes, but provider Todd Cressler was on top of it.

"We have the handouts going out already to all the referral sources to let them enjoy the further requirements of going from PAP to Bi-Level," said Cressler, president/CEO of Harrisburg, Pa.-based CressCare Medical. "The physicians are not going to be happy but we're just following the rules."

These latest requirements, on top of those that went into effect in November of 2008, could be the final straw for many providers, who find it too cumbersome--and expensive--to continue serving Medicare beneficiaries.

"Medicare is making things so hard you are going to have more people say 'I am just not going to do this anymore,'" said Kent.