Positive Airway Pressure (PAP) - Practitioner
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Ordering/Treating Practitioner Issues
- The local coverage determination (LCD) uses the term "treating practitioner" in various places. What is the definition of a treating practitioner?
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The term treating practitioner encompasses both physicians (defined in section 1861(r)(1) of the Social Security Act) and non-physician practitioners (such as a physician’s assistant [PA], nurse practitioner [NP], and clinical nurse specialist [CNS]; defined in section 1861(aa)(5) of the Social Security Act). In a scenario where the beneficiary visits their primary care provider (PCP) who then refers the beneficiary to a sleep specialist for a polysomnogram and subsequent treatment with PAP and follow-up, both the PCP and the sleep specialist would be considered "treating practitioners" within the context of Medicare regulations. Both practitioners are engaged in diagnosing and treating the beneficiary for sleep disordered breathing. This scenario is quite common in medical practice where the primary medical care for the beneficiary is rendered by the PCP and subspecialty practitioner consultation is engaged for specific diagnostic and/or therapeutic treatment outside the scope of the PCP's area of medical expertise.
Originally published: 02.20.17
Reviewed: 12.06.23
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- Can a registered nurse (RN) conduct the follow-up evaluation?
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No, the treating practitioner must be directly involved in the follow-up evaluation.
Originally published: 02.20.17
Reviewed: 12.06.23
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- The policy states that the data that the practitioner evaluates must be for a period of 30 consecutive days. The policy is silent on a time frame in which the practitioner must see the beneficiary in relationship to the data.
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The practitioner may see the beneficiary and conduct the follow-up evaluation between the 31st and 91st day. Continued coverage of a PAP device requires that a determination be made by the treating practitioner that the beneficiary is benefiting from the use of the selected device as evidenced by an in-person clinical follow-up evaluation and adherence to therapy. While the documentation of adherence may occur following the treating practitioner's follow-up evaluation, the adherence report must be provided to the treating practitioner for inclusion in the beneficiary's medical record in order to fulfill the requirement to assess therapy benefit. Consider the following example:
- 11/01/14 – Beneficiary set up with a PAP device
- 12/05/14 – In-person re-evaluation indicates subjective improvement, but objective data is not available
- 1/30/15 – Supplier obtains data demonstrating adherent use; faxes to MD for review
- 2/01/15 – Add KX modifier to fourth month's claim
Originally published: 02.20.17
Reviewed: 12.06.23
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- Is there a time limit from initial in-person evaluation to the sleep study?
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No time limit is specified in the policy; however, one would anticipate that these two events occur reasonably close together in time, typically within three months.
Originally published: 02.20.17
Reviewed: 12.06.23
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- Explain the practitioner visits required for beneficiaries who are being evaluated for sleep disordered breathing.
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Two in-person evaluations are required for Medicare coverage of PAP therapy. One of these visits is required for consideration of initial coverage (coverage for the first three months of therapy) and the other visit is required for consideration of continued coverage of therapy (coverage for the fourth month and beyond).
The initial coverage visit is an in-person interaction between the treating practitioner and the beneficiary, which (1) occurs prior to the sleep test and (2) assesses the beneficiary for obstructive sleep apnea (OSA). Commonly documented elements in this in-person visit include (but are not limited to):
- Sleep history and symptoms
- Epworth Sleepiness Scale (a standardized patient questionnaire which helps to assess the likelihood of sleep apnea) or other validated sleep inventory
- Pertinent physical examination - such as body mass index, neck circumference, upper airway exam, and cardiopulmonary exam
Medicare coverage is conditional for the first three months. Continued coverage beyond the first three months is contingent upon demonstration of benefit from the use of a PAP device. Therefore, following the sleep test, the beneficiary must see the treating practitioner again, sometime between the 31st and 91st day of therapy, to document improvement of the beneficiary's symptoms. In addition, the practitioner must review data from the PAP device which documents use at least four hours per night on 70% of nights for a 30 consecutive day period during the trial.
Originally published: 02.20.17
Reviewed: 12.06.23
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- The LCD for PAP devices defines hypopnea 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. If the supplier receives a copy of a polysomnogram (PSG) that is scored at 3% instead of 4%, is it acceptable to have the PSG rescored and add an addendum to the original interpretation documenting the apnea hypopnea index (AHI) scored at 4%?
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Yes, adding an addendum would be acceptable, as long as the addendum is added correctly, according to CMS record keeping principles. The addendum added to the original PSG must be signed and dated by the original interpreting practitioner. In cases where the original interpreting practitioner is no longer available to read the study and score it based upon the 4%, it is not acceptable to add an addendum to the original study. In this situation, however, the "new" interpreting practitioner may document the PSG results for 4% in the beneficiary's medical record, and this will be accepted.
Originally published: 10.21.19
Reviewed: 12.06.23
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- Can the supplier resume billing the 4th rental month once the beneficiary becomes compliant? For example: January 1 is the initial set-up, and they are not compliant by the end of March (the 12-week trial). In April, they are able to schedule a re-evaluation and sleep test. In mid-May, their download shows adherence to therapy per LCD guidelines. Can the supplier resume billing month four in mid-May since they have reached compliance?
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Yes. The documentation must show that the beneficiary has met compliance no sooner than the 31st day of the second 12-week trial (in this example, it was completed in April). Once compliance has been met, the supplier may resume billing the 4th rental month and append the KX modifier. In the given example, billing would resume in May.
Originally published: 10.21.19
Reviewed: 12.06.23
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- If the compliance wasn’t met after the first re-trial, can a second re-trial be initiated?
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The Positive Airway Pressure (PAP) Devices for Obstructive Sleep Apnea policy does not limit the number of trials in which the beneficiary may attempt to re-qualify for PAP therapy. The policy does, however, outline specific requirements that must be met in order for a retrial to be initiated. Additionally, suppliers will only be able to bill Medicare for the PAP device once compliance is met.
Originally published: 10.21.19
Reviewed: 12.06.23
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