If you are PAP device provider, you are aware of the audits occurring, whether it’s pre-pay, post-pay, RAC, etc.,if it’s PAP device equipment, it’s getting an audit.
Information has been gathered from the results of various audits and listed below are the top 5 denial reasons. I thought it would also be valuable to pull together some helpful tips that should assist in overcoming those audits.
- No face-to-face clinical evaluation by the treating physician prior to the sleep test to assess the beneficiary for OSA.
- No documentation of a face-to-face evaluation by the treating physician for replacement following the 5 year RUL that the beneficiary continues to use and benefit from the device.
- The supplier’s records did not document that the beneficiary and/or their caregiver received instruction in the proper care of the PAP device and accessories.
- The beneficiary began using PAP prior to Medicare eligibility and the documentation did not include a F2F evaluation conducted following enrollment in FFS Medicare or the note did not record that the beneficiary had a diagnosis of OSA and continued to use and benefit from PAP therapy.
- The documentation did not include a copy of a board certification document, screen print from a national certification agency, etc. that verifies that the physician who interpreted the sleep test met policy requirements.
The key is to be sure to have documentation that includes an assessment for OSA that occurred in the face-to-face evaluation. This documentation would generally include pertinent information about the signs and symptoms of the sleep disorder, duration of symptoms, cardiopulmonary and upper airway exam, neck, circumference, and BMI.
When a patient is replacing the equipment following the 5-year reasonable useful lifetime, that a face to face evaluation has occurred documenting the use and benefits from the device.
When you receive a letter from an auditor, be sure to read it thoroughly and know what they are requesting. Make sure you send just the information they are requesting, numbering the pages and list a table of contents of the documents that are included in the packet.
Remember, a diagnosis and medication list alone are not sufficient to justify medical necessity in the medical records. Also,a good rule of thumb is if it’s not documented, it did not happen.
Please use this information as a reference for your PAP referrals. I have also included a documentation checklist that is very valuable when receiving a PAP patient.
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