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By Donna Youngblood RN, BSN, CPC

If you are a supplier that dispenses Positive Airway Pressure (PAP) devices and/or supplies then you should be familiar with the Local Coverage Determination (LCD) that includes coverage criteria for PAP therapy. The LCD also includes the definitions of common terminology that you would find in a polysomnogram (PSG) or sleep study. Many suppliers miss Medicare’s definition of hypopnea which is defined as “an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thoracoabdominal movement or airflow as compared to baseline, as with at least a 4% decrease in oxygen saturation". Suppliers are reviewing sleep studies to verify that the AHI or RDI includes the minimum number of events to meet Medicare requirements; however, you also must make sure the study is being scored according to Medicare requirements.

In August 2019, a Dear Physician letter was released discussing scoring of sleep studies. The letter states that the American Academy of Sleep Medicine (AASM) guidelines for scoring of hypopneas differs from the Medicare definition. AASM uses a 3% decrease in oxygen saturation when scoring hypopneas which may result in a higher AHI or RDI. The number of events (AHI/RDI) may meet the number specified in the LCD but they would not necessarily qualify since there were not scored using a 4% desaturation. If you are reviewing a sleep study that does not indicate how it was scored (3% vs. 4%) Medicare will deny your claim in the event of an audit.

What should you do?

When you are reviewing a sleep study for Medicare coverage, you must look for scoring criteria as well as other coverage criteria such as AHI/RDI. If scoring is not indicated, you must query the sleep center for their scoring criteria. If the study indicates it was scored using a 3% desaturation, then ask the sleep center to rescore using a 4% desaturation. In some cases, the sleep center may include both the AASM (3%) and CMS (4%) scores for coverage purposes.

Need help?

Our clinical consultants can review your PAP claims including sleep studies to determine if these guidelines are met and provide education on how to make sure you are meeting coverage criteria.  Contact Us today for more information!