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On February 20, 2019, the Supplemental Medical Review Contractor (SMRC) Noridian Healthcare Solutions, published project "01-010 Replacement PAP Device Supplies and Accessories Notification of Medical Review" to their current projects list.

While this should come as no surprise as we know multiple suppliers have been receiving these audit requests since late 2018, it is nice to see Noridian officially acknowledge the project and post information to their website.

The SMRC audit is a post-payment review of claims for services billed on dates of service from January 1, 2017, through December 31, 2017.

Medicare covers replacement supplies for positive airway pressure (PAP) devices only when suppliers document that the supplies remain reasonable and necessary. Previous Office of Inspector General (OIG) reviews found that Medicare allowed replacement of PAP device supplies more frequently than was reasonable and necessary and that durable medical equipment (DME) suppliers often did not have the documentation required to support the need for replacement supplies.

According to OIG report A-04-17-04056: “Most Medicare Claims for Replacement Positive Airway Pressure Device Supplies Did Not Comply with Medicare Requirements” dated June of 2018, of the 110 claims in the stratified random sample, 86 did not comply with Medicare requirements. Based on these results, the OIG estimated that Medicare made overpayments of an estimated $631.3 million for replacement PAP device supply claims that did not comply with Medicare requirements.

Reason for Review
In response to the OIG report, the CMS tasked Noridian, as the SMRC, to perform data analysis and conduct medical review. Noridian will complete medical record review to determine if suppliers billed in accordance with statutory, regulatory and subregulatory guidance.

Codes under Review 

  • A4604: Tubing with integrated heating element for use with positive airway pressure device
  • A7027: Combination oral/nasal mask, used with continuous positive airway pressure device, each
  • A7028: Oral cushion for combination oral/nasal mask, replacement only, each
  • A7029: Nasal pillows for combination oral/nasal mask, replacement only, pair
  • A7030: Full face mask used with positive airway pressure device, each
  • A7031: Face mask interface, replacement for full face mask, each
  • A7032: Cushion for use on nasal mask interface, replacement only, each
  • A7033: Pillow for use on nasal cannula type interface, replacement only, pair
  • A7034: Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap
  • A7035: Headgear used with positive airway pressure device
  • A7036: Chinstrap used with positive airway pressure device
  • A7037: Tubing used with positive airway pressure device
  • A7038: Filter, disposable, used with positive airway pressure device
  • A7039: Filter, non-disposable, used with positive airway pressure device
  • A7046: Water chamber for humidifier, used with positive airway pressure device, replacement, each

Documenation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review. Documentation requested has been made specific to assist the provider in collecting and submitting pertinent information to decrease provider burden.

  1. Valid physician or non-physician practitioner order for the PAP supplies and accessories billed
  2. Medical record documentation to support the beneficiary’s continued need for PAP device or PAP device supplies and accessories
  3. Timely refill request documentation for each accessory or supply billed
  4. Proof of delivery showing sufficient content to identify the beneficiary’s receipt of each supply or accessory billed
  5. Legible handwritten or valid electronic signature and signature log, if acceptable
  6. Advance Beneficiary Notice of Noncoverage (ABN), if applicable

For more information, visit the SMRC website at www.noridiansmrc.com

If you have received a SMRC request and would like assistance or guidance with your response, contact us!

Our clinical experts can review your patient files and and help with your audit response. If overpayments are determined, our consultants can help you with the submission process. For more information contact us today!