PAP Device Helpful Reminders

PAPDevice Helpful Reminders

As with all other DMEPOS, PAP devices are getting heavily audited at all levels of audits.  Here are some helpful reminders when receiving those PAP referrals.  For starters, remember a PAP device (E0601) or the BiPAP device (E0470) when used under the PAP policy the only diagnosis code that is acceptable for use with obstructive sleep apnea (OSA) which is 327.23.

  1.  Face to face clinical evaluation must occur in the following scenarios:
    1. Patient is seeking initial coverage of a PAP device, the face to face must occur prior to the sleep study to assess for OSA.
    2. Patient needs a replacement PAP device following a 5 year RUL.
    3. Patient needs a replacement PAP device upon entering traditional Medicare.
  2. For those patients seeking replacement PAP devices, the clinical documentation needs to include improvement in OSA symptoms and the patient continues to benefit from the sleep therapy.
  3. Make sure to document the training on the PAP device with the patient and/or caregiver.  You have to have evidence of training on the equipment.   Keep this in mind:  if it’s not documented, it did not happen.
  4. The patient is required to have a re-evaluation no sooner than the 31st day but no later than the 91st day after initiating therapy.  The treating practitioner must conduct a clinical re-evaluation and document that patient is benefiting from PAP therapy and that the symptoms of OSA are improved.
  5. If a patient needs to be assessed for oxygen for use with the PAP device, the patient needs to be in a chronic stable state which means the overnight oximetry must be performed during a titration study in a facility. Those patients with an underlying lung disease such as COPD that are using a PAP device must have a titration study performed to consider coverage for oxygen.  The reasoning is to make sure the patient is at their optimal pressure on the PAP device before initiating oxygen therapy. 

Remember,E0601 and E0470 are part of the face to face rule from the Affordable Care Act that was implemented July 1, 2013.  This means the medical record and detailed written order need to be obtained prior to the delivery of equipment.  Although the enforcement is delay until “a date” in 2014, suppliers need to or should already be implementing this process now.

Along with this article is an example of an acceptable versus an unacceptable order.

Ronda Buhrmester

Phone:  888-665-6518    Fax:855-262-3821