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By Donna Youngblood RN, BSN, CPC

There are many different scenarios for patients requiring replacement PAP supplies. Common scenarios include the need for new supplies during the 13-month rental after initiation of PAP therapy, needing supplies for patient owned equipment, and those patients that are new to fee-for-service (FFS) Medicare. Not all these scenarios are alike but a good intake process should ensure that you pass an audit.

Commons scenarios and documentation requirements that you should be making sure you have present in your files.

1. FFS Medicare – initiation of PA therapy
   1. Initial face-to-face – must document symptoms of OSA and need for a sleep study
   1. Qualifying sleep study (diagnostic or split-night) – AHI/RDI > 5 events per hour, scoring based on 4% desaturation
   1. Re-evaluation between 31^st-91^st day after PAP device was delivered – must document patient is using PAP and benefiting
   1. Adherence to therapy – compliance download (30 consecutive days=70% or better) with provider’s signature OR data mentioned within progress note
2. Patient owned PAP device – paid by Medicare
   1. Verify that Medicare paid for 13 months’ rental
   1. DWO for PAP supplies
   1. Face-to-face documenting continued medical need of PAP therapy (dated within 12 months from DOS)
3. Patient owned PAP device – entering FFS
   1. Qualifying sleep study (diagnostic or split-night) – AHI/RDI > 5 events per hour, scoring based on 4% desaturation
   1. Face-to-face evaluation on or after enrollment date documenting diagnosis of OSA and use of PAP therapy
   1. Continued medical need supported by DWO and progress note dated within 12 months from DOS
4. Patients wanting PAP supplies ONLY –
   1. Qualifying sleep study (diagnostic or split-night) – AHI/RDI > 5 events per hour, scoring based on 4% desaturation
   1. Face-to-face evaluation documenting diagnosis of OSA and use of PAP therapy dated within 12 months from DOS

WHAT YOU SHOULD DO?

If you are a supplier that provides replacement PAP supplies, you need to look at your current processes related to these findings and make corrective actions to avoid claim denials. An order with all the required elements should be on file prior to submitting a claim. Required elements include beneficiary’s and physician’s names, the date of the order, a detailed description of the items to be dispensed, the quantity to be dispensed, the frequency of use, and the number of refills. The supplier must also obtain a new order when there is a change in supplier, supplies, frequency or quantity of use, or length of need.

Documentation of a request for supplies from the beneficiary must be on record to support supplies are reasonable and necessary. A refill request must contain the date of the request, the description of each item requested, and the condition of the items being replaced in sufficient detail to demonstrate why they need to be replaced. Contact with the beneficiary must occur no more than 14 days prior to filling the order for replacement PAP supplies.

A valid sleep study should be on file for those patients receiving replacement PAP supplies. A valid sleep study includes scoring criteria using a 4% desaturation for hypopneas and a qualifying AHI/RDI.

Suppliers must obtain documentation to support continued medical need for and use of PAP therapy. Documentation must be dated within 12 months from the date of service and may be from the beneficiary’s medical record or as a recent order. When dispensing supplies, suppliers must provide no more than three months of supplies. Delivery records must include the shipping service’s delivery ticket with identification number to support supplies were delivered to the beneficiary or a signed direct delivery ticket.

HOW WE CAN HELP?

Before dispensing PAP supplies, let our clinical staff review your records to ensure the proper documentation is present that meets coverage criteria. Our proactive audit services can review a sample of your claims billed to Medicare and identify areas of weakness needing to be addressed to avoid overpayments. We can also be help during a TPE audit of PAP supplies and ensure that you are submitting the correct documentation to pass these reviews. Contact us today for more information!