Here is a question I get all the time:

I have a new patient eligible for a five-year CPAP replacement, but we are having a hard time getting a copy of the patient’s original sleep study. Medicare paid a different supplier for the initial equipment. Do we have to send the patient back for a new sleep study?

Sound familiar?

The good news is I have a short cut that may save you and your new patient a lot of time and hassle.

Next Episode: Thursday, June 20, 2024

An Easier Way to Document Medical Necessity

According to Medicare’s PAP Policy Article, if Medicare made 13 payments for the new patient’s existing equipment, “the medical necessity for the beneficiary-owned base PAP is assumed to have been established.” That is to say, suppliers that did not provide the original equipment can use evidence of 13 Medicare payments in lieu of the original sleep study and face-to-face documentation.

Suppliers can use the same and similar search functions in DME MAC portals to easily determine the number of Medicare payments made for the existing equipment … much easier than chasing down the prior supplier, physician, sleep lab, and patient for old eligibility documents.

In the case above, the new supplier can rely on a current face-to-face visit documenting continued use and benefit of PAP therapy to justify equipment replacement. I do recommend printing out evidence of the previous 13 Medicare payments and saving it in the supplier’s patient file to support claims for the new equipment and any related supplies.

What if Medicare Did Not Make 13 Payments?

Unfortunately, this only applies when Medicare paid 13 payments for the original equipment. If they paid less than 13, or if the original equipment was covered by another insurance carrier, the new supplier must reaffirm the OSA diagnosis by producing a sleep study that meets Medicare requirements. The study does not necessarily need to be the original, but it does need to meet the Medicare definition for the apnea hypopnea index by scoring hypopneas using a four percent drop in the oxygen saturation levels. A three percent drop as scored by AASM accredited labs will not qualify.

Ultimately, suppliers can often save significant time by checking DME MAC portals for evidence of 13 Medicare payments before spending days or weeks tracking down prior documentation … or sending patients back to the doctor for requalification.