2nd Quarter results for widespread prepayment reviews on CPAP devices (E0601)

The Medical Review Department is conducting a widespread complex review of HCPCS code E0601 for the first month of billing (KH modifier) and the 4th thru 13th month of billing (KJ modifier). The second quarter edit effectiveness results from July 2012 through October 2012 are as follows:

The KH modifier review involved 2172 claims of which 1338 were denied. This resulted in an overall error rate of 62%.

The KJ modifier review involved 1941 claims of which 1406 were denied. This resulted in an overall error rate of 74%.

Top reasons for denials:

  1. Criterion A was not met which means no face to face was performed prior to the sleep study.
  2. Signature requirements were not met. 
  3. Criterion B was not met which means the AHI was not qualifying according to the LCD.
  4. Documentation was not received within the timeframe allowed per the guidelines.
  5. Criterion one was not met for continued coverage beyond the first three months.

 

According to the Positive Airway Pressure LCD, the beneficiary has to have a face to face with the treating physician prior to the sleep study to assess for obstructive sleep apnea.   The provider needs to work with the sleep lab centers and referrals to ensure the face to face examination is being performed prior to the sleep study.

Medicare requires that services provided/ordered be authenticated by the author per the Program Integrity Manual. (3.3.2.4); Stamped signatures are not accepted.

The beneficiary has a sleep test that meets one of the following criteria:  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, 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 excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia, or hypertension, ischemic heart disease, or history of a stroke.

In order to get coverage beyond the first three months for a PAP device (E0470 or E0601), requires that no sooner than the 31st day but no later than the 91st day after initiating therapy , the treating physician  must conduct a face to face clinical re-evaluation and document that the beneficiary is benefiting from the PAP therapy.  The patient must also have a compliance of 70% of nights during a consecutive 30 day period with at least 4 hours per night during the first three months of initial usage.

There are suppliers still in failing to responding to the request for records.  This is a violation of the Supplier Standard #28.

 

There are documentation checklists for PAP devices available on each Jurisdiction website that lists the information required when submitting the claim.

 

Feel free to contact Ronda Buhrmester at VGM & Associates at 888-665-6518 or email questions to [email protected]