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Fact Sheet

Positive Airway Pressure (PAP) Accessories and Supplies Medical Record Documentation Fact Sheet

Use this fact sheet to quickly understand the medical record documentation requirements for accessories such as interfaces, tubing, filters, humidifier chambers under these three scenarios:

Beneficiaries Entering Medicare: Replacement of Accessories during the 13-month capped rental period for the PAP device: Replacement of Accessories for Medicare-Paid, Beneficiary-Owned PAP devices:
  • Sleep test – There must be documentation that the beneficiary had a sleep test prior to Fee-for-Service (FFS) Medicare enrollment. The sleep test must meet the Medicare AHI/RDI coverage criteria in effect at the time that the beneficiary seeks Medicare coverage.
  • Clinical Evaluation – After enrollment in FFS Medicare, the beneficiary must have an in-person evaluation by their treating practitioner who documents in the medical record:
    • The beneficiary has obstructive sleep apnea; and,
    • Continues to use the PAP device.
  • Sleep test information that verifies the beneficiary meets the AHI/RDI coverage criteria in the local coverage determination (LCD).
  • Documentation supports the diagnostic sleep test met coverage and reimbursement requirements in CMS NCD 240.4.1 and A/B MAC LCDs and Billing and Coding articles.
  • In-person clinical evaluation occurred prior to the diagnostic sleep test and assessed the beneficiary for obstructive sleep apnea (OSA).
    • Documentation of Obstructive Sleep Apnea (OSA) diagnosis
    • The beneficiary and/or caregiver received instructions from the supplier in the proper use and care of the equipment.
  • Documentation that the base item continues to meet medical need.
  • Documentation that the replacement of specific accessories or furnishing of new accessories are still medically necessary and are essential for the effective use of the device.
  • Verify continued medical need for the supplies:
    • A recent order by the treating practitioner for refills of supplies.
    • A recent order by the treating practitioner for repairs.
    • A recent change in an order.
    • Timely documentation in the beneficiary’s medical record showing usage of the item.

Timely documentation: A record in the preceding 12 months unless specified elsewhere in the policy.

Resources:

Published: June 6, 2024

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