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Polysomnography and Other Sleep Studies. Medicare Part B and Durable Medical Equipment (DME) Provider Outreach and Education (POE) March PDF

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Polysomnography and Other Sleep Studies Medicare Part B and Durable Medical Equipment (DME) Provider Outreach and Education (POE) March 2016 DISCLAIMER This information release is the property of Noridian
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Polysomnography and Other Sleep Studies Medicare Part B and Durable Medical Equipment (DME) Provider Outreach and Education (POE) March 2016 DISCLAIMER This information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided as is without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and CMS. The most current edition of the information contained in this release can be found on the Noridian website at and the CMS website at The identification of an organization or product in this information does not imply any form of endorsement. CPT codes, descriptors, and other data only are copyright 2016 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. March Helpful Acronyms ABN AHI CCI CPAP CR F2F FFS HST Advance Beneficiary Notice Apnea-Hypopnea Index Correct Coding Initiative Continuous Positive Airway Pressure Change Request Face-to-Face Fee for Service Home Sleep Testing March Helpful Acronyms 2 IDTF IOM NSC OIG OSA PSG RDI Independent Diagnostic Testing Facility Internet Only Manual National Supplier Clearinghouse Office of Inspector General Obstructive Sleep Apnea Polysomnography Respiratory Disturbance Index https://www.cms.gov/apps/acronyms/ March Agenda Polysomnography and Sleep Studies Includes Home Sleep Studies Polysomnography and Home Sleep Testing Requirements for DME Physician Documentation Resources March Objective To educate providers with Medicare Part B expectations for those involved with sleep studies To provide both DME suppliers and providers education regarding Medicare CPAP and OSA coverage and documentation requirements March Polysomnography & Sleep Studies March ICD-10 Diagnoses Check policy on Noridian website containing updated ICD-10 diagnoses Active Policy as of 10/1/15 Slide 65 has links March Polysomnography Overview Continuous monitoring/recording of physiological sleep parameters (6 hours/more) Overnight stay at sleep lab or IDTF Hospital or freestanding facility Performed by trained technician to monitor/assess patient Under supervision of/referred by attending physician for review/interpretation/report IOM Publication , Chapter 1, Section March Polysomnography Overview 2 Patient referred by attending physician Sleep must be recorded/staged Diagnose/evaluate many sleeping disorders types Sleep Apnea (common dissomonia) Narcolepsy Sleep-related asthma/depression/panic disorder Other disorders during sleep (parasomnias) Including dental/medical/psychiatric Sleep behavior disorders March Polysomnography Overview 3 Not considered inpatient Even though spending night in hospital or freestanding clinic Overnight oximetry indicates desaturation to below 90%, greater than 5% of the time Not Covered Chronic Insomnia Two week home auto CPAP titration study Cannot bill patient per Non Covered Policy as part of Group 2 - Components of Another Service, Never Separately Billable to Contractor or Patient March Beneficiaries Entering Medicare Beneficiary seeking rental/replacement PAP and/ or accessories must meet these requirements: 1. Sleep test prior to FFS Medicare that meets AHI/RDI criteria in effect at the time a replacement PAP and/or accessories are needed, and 2. FTF evaluation following enrollment in FFS Medicare by treating physician that documents a) Diagnosis of OSA; and b) Beneficiary continues to use the PAP device If above not met, claim denies as not reasonable and necessary March Testing Definitions Apnea Cessation of airflow for at least 10 seconds Hypopnea Abnormal respiratory event lasting at least 10 seconds With minimal 30% reduction in thoracoabdominal movement or airflow as compared to baseline At least a 4% decrease in oxygen desaturation March Who Can Perform? Polysomnographic or Electrodiagnostic Technologist Courses include: Instrumentation Recording/Monitoring Record Scoring Sleep Disorders Need to add new/additional sleep lab techs? Noridian Enrollment requires copies of license/certificate HSTs (Type II, III or IV) must be physician interpreted Physician specialty code = CO Sleep medicine services (CR 7600) March Interpreting Physician Requirements Current certification in Sleep Medicine by the American Board of Sleep Medicine (ABSM); or, Current subspecialty certification in Sleep Medicine By a member board of the American Board of Medical Specialties (ABMS); or, Completed residency/fellowship training by an ABMS member board Completed all requirements for subspecialty certification in sleep medicine (except the examination itself) and only until the time of reporting of the first exam which physician eligible; or, Active staff membership of a sleep center or laboratory Accredited by the American Academy of Sleep Medicine (AASM), Accreditation Commission for Health Care (ACHC) or The Joint Commission (TJC, formerly Joint Commission on Accreditation of Healthcare Organizations JCAHO) March Technician Certification Technician must be credentialed OR certified with one or more of the following: American Academy of Sleep Medicine (AASM) (www.aasmnet.org) American Board of Sleep Medicine (ABSM)-Registered Sleep Technologist (RST) Accreditation Commission for Health Care (ACHC) (www.achc.org) Board of Registered Polysomnography Technologists (BRPT)-Registered Polysomnographic Technologist (RPSGT) (http://www.brpt.org/) March Equipment IDTF has to contain the following stationary equipment: EEG (electroencephalogram) measures and records brain wave activity EMG (electromyogram) records muscle activity such as face twitches, teeth grinding and leg movements; helps determine REM stage sleep EOG (electro-oculogram) records eye movements; important in determining different sleep stages, particularly REM stage sleep EKG (electrocardiogram) records heart rate and rhythm Nasal airflow sensor records airflow Snore microphone records snoring activity March Where Performed? Sleep Studies and Polysomnography (PSG) 95808, & POS 11 = IDTF or facility-based sleep laboratory Not home (12) or mobile IDTF facility (15) Complies with state regulatory requirements POS 24 = Ambulatory Surgical Center (24) Home Sleep Testing (HST) G0398 G0400 POS 12 = Home POS 15 = Mobile IDTF Professional (-26) portion only March Sleep Lab Enrollment Enroll with CMS 855B in preferred online PECOS List all CPT codes IDTF intends to bill Equipment listing (Att. #2) name/model # equipment IDTFs comprehensive liability insurance copy Facility and/or physician certification for sleep lab List all interpreting (if billing globally), supervising physicians and technicians with copy of their medical license Technician s certification and/or licensure copies All other documentation required (IRS forms, business license, EFT form {CMS-588} and PAR Agreement {CMS-460}, etc.) MSM is the National Site Visit Contractor (see next slide) Inspects facility, paperwork and equipment March National Site Visit Contractor Before approving Medicare enrollment, CMS hires separate contractors to visit potential sites MSM Security Services, LLC Subcontractors include Health Integrity, LLC (HI) & Computer Evidence Specialists, LLC (CES) Has screening mechanism to prevent questionable providers from enrolling in Medicare Employees from above contractors Carry Photo ID and Authorization Letter signed by CMS for provider to review National Supplier Clearinghouse (NSC) enrolls DME suppliers Certification/MedicareProviderSupEnroll/index.html March Patient Needs Constant Monitoring Electroencephalography (EEG) Records brain wave activity May detect seizures Electrooculography (EOG) Records eye movement Both EEG/EOG helpful March CPT Codes CPT DESCRIPTION Sleep Study; Unattended Sleep Study; Unattended Multiple Sleep Latency Test Sleep Study; Unattended Sleep Study; Attended Polysomnography Polysomnography 4 or more Polysomnography with CPAP March Providers In Other States Each provider enrolls/bills from their state E.g. Nevada and Washington Provider must reflect their address in Item 32 Separate interpretation no billing global TC/26 POS CPT/Mod Technical (Sleep Tight IDTF-Reno, NV) TC Professional (Dr. Medi Care-Seattle, WA) March CPT DESCRIPTION HCPCS Codes G0398 Home Sleep Study Test (HST) with Type II portable monitor, unattended, minimum of 7 channels G0399 Home Sleep Study Test (HST) with Type III portable monitor, unattended, minimum of 4 channels G0400 Home Sleep Study Test (HST) with Type IV portable monitor, unattended, minimum of 3 channels E.g. Watch-PAT devices (Itamar Medical) March Technical / Professional Example Never appropriate to bill different CPT/HCPCS TC/26 codes for single study Technical portion in Oregon G0399-TC Provider bills to Oregon Medicare Professional portion in California G Provider bills to California Medicare Actual delivery of service point = place of service March Non Covered CPT/HCPCS Investigational, Not Proven Effective or Experimental CPT DESCRIPTION 0243T Intermittent bronchodilator wheeze rate measurement 0244T Continuous treatment measurement wheeze rate Unlisted Palate Implant Procedure (Pillar System) March Actigraphy (Actigraphy testing, recording, analysis, interpretation and report) Minimum of 72 hours to 14 consecutive days recording Do not report more than once in 14-day period MUE = 1 Continuous measurement of activity/movement with the use of small device called actigraph With push of a button, also marks events Such as bedtimes or wake times Noridian Medicare covers either (global) TC or March Epworth Sleepiness Scale Not covered by Medicare For E/M, not separately billable Part of History of Presenting Illness (HPI) Epworth sleepiness scale Evaluating sleep records accurately 8 possible questions establishing sleep quality Part of intake for pulmonary sleep to determine severity/quality March Modifiers Situation Home sleep study incomplete/patient discontinues/less than 6 hours reduce billing charges Oxygen saturation only one hour/inadequate for interpretation reduce billing charges too Patient misses day follow up with physician, ABN needed Hospice patient treated - unrelated to terminal condition Append Modifier GA GW March Miscellaneous Tips Sleep Medicine codes unchanged for alone does not describe device type Providers must document Type II, III or IV Never bill twice for Single component or Single sleep study No defined face-to-face time prior to sleep study unless extensive (e.g. over 3 months) E/M and PSG same day approved IF CCI met March Miscellaneous Tips 2 New F2F prior to repeat/re-evaluated sleep study Reduce billing/append modifier 52 ONLY if incomplete sleep study Fewer than 6 hours recorded sleep study Oxygen saturation period only last 1 hour; inadequate for interpretation PAP-Nap no coverage/code for Medicare 2 hour afternoon nap (CPAP titration study) Noncovered per NCD policy March Miscellaneous Tips 3 Maintenance of Wakefulness Test? (multiple sleep latency, recording, analysis, interpretation of physiological measurements of sleep during multiple trails to assess sleepiness) Appropriate, if all components performed and documented EEG interpretation is required component of polysomnography; billed as and cannot bill separately March Miscellaneous Tips4 Both polysomnography testing and 24-hour electrocardiographic holter monitoring can be billed if: Medically necessary; separate equipment used for ECG monitoring (PSG equipment with ECG lead and a holter monitor device) Separate interpretation/report is done for each procedure Code for polysomnography is and the code range for holter monitoring is March Provider Questions Q1) How do we handle if patient needs a repeat study? A1) This will depend on the circumstances requiring the new study. For example: If therapy has been discontinued and reevaluation to resume therapy is occurring, then the process must start from the beginning. If the trial period has failed, there is a requirement for F2F and another study. Q2) Is there a limit to how many sleep studies a Medicare beneficiary may have in a lifetime? A2) While there is no limit, each test must of its own accord, be reasonable and necessary. Generally, an initial diagnostic PSG and one follow up to titrate for effectiveness should be all that is needed for several months unless there is an extraordinary change in the patients well being. March Appeals Include all relevant medical records If needed, pertinent peer-reviewed literature to support request March ZPIC Contractor CMS Zone Program Integrity Contractor (ZPIC) Performs data analysis, investigation and medical review to detect, prevent, deter, reduce and present referrals to recover fraud, waste and abuse with utilization measures analyzed E.g. Includes 9 sleep study codes, NOS and beneficiaries billed to Medicare more than twice/year March OIG Report Polysomnography Services Questionable Billing OIG examines physicians, hospital outpatient and IDTFs to assess payment appropriateness; i.e. Inappropriate diagnosis code Repeated polysomnography services Missing visit with ordering provider Missing or double billing professional component Titration with no corresponding treatment device Unbundling a split-night service pdf March Polysomnography and Home Sleep Testing Requirements for DME CPAP Initial Coverage OSA 12 Week Trial A. Face-To-Face (FTF) clinical evaluation by treating physician prior to a sleep test assessing patient for OSA B. Medicare covered sleep test that meets either one of the following criteria AHI or RDI 15 events per hour with a minimum of 30 events or AHI or RDI 5 14 events per hour with a minimum of 10 events and documentation of: Excessive daytime sleepiness, impaired cognition, mood disorders or insomnia; OR Hypertension, ischemic heart disease or history of stroke C. Patient or caregiver received instruction from supplier in proper use and care of CPAP (E0601) March Coverage for Bi-level Without Backup D. Bi-level respiratory assist device without backup (E0470) is covered for patients with OSA if patient meets initial coverage criteria A - C and: CPAP tried and proven ineffective Based on therapeutic trial conducted in either a facility or home setting Coverage criteria not met Device will deny not reasonable and necessary Supplier liability March Treating Physician s Initial Evaluation Physician FTF initial evaluation Written in the same format that are used for other entries and may include: History Signs and symptoms of sleep disordered breathing including snoring, daytime sleepiness, observed apneas, choking or gasping during sleep, morning headaches Duration of symptom Validated sleep hygiene inventory such as the Epworth Sleepiness Scale (see Appendices) Exam Focused cardiopulmonary and upper airway system evaluation Neck circumference Body mass index (BMI) March Continued Coverage Beyond 12 Weeks Clinical re-evaluation between 31st and 91st day after initiating therapy Treating physician documents benefiting from therapy; and Objective evidence of adherence reviewed by treating physician Used 4 hours per night 70% of nights during a consecutive thirty day period anytime during the first three months of initial usage Supplier provides treating physician with objective data related to adherence Through direct download or visual inspection of usage data with documentation provided in a written report format to be reviewed by the treating physician and included in the beneficiary s medical record Adherence to therapy not documented within first three months, patient fails trial period March Treating Physician s Re-evaluation May not be documented before the 31st day Must document Improvement in subjective symptoms of OSA Objective data related to adherence Through direct download or visual inspection of usage data with documentation provided in a written report format to be reviewed by the treating physician and included in the beneficiary s medical record March CPAP to RAD Evaluation, Trial, Adherence During initial three month trial Does not change length of trial if more than 30 days remain Re-evaluation between 31 st and 91 st day Adherence to therapy on the RAD prior to 91 st day Less than 30 days remain in trial Re-evaluation must occur before the 120th day Adherence to therapy on the RAD before the 120 th day After initial three month trial New initial face-to-face evaluation New three month trial with the RAD Clinical re-evaluation between 31st and 91st day with RAD Adherence to therapy with RAD March Documentation Switching from CPAP to RAD Treating physician must document follow issues were addressed prior to changing: A. Interface fit and comfort This properly fit interface will be used with the E0470 B. E0601 pressure settings prevents tolerating therapy and lower settings of the E0601 were tried but failed to: Control symptoms of OSA; or Improve sleep; or Reduce AHI/RDI to acceptable levels March Re-evaluations Occurring After 91st Day Physician documents benefiting from therapy and Objective evidence of adherence reviewed by treating physician Used 4 hours per night 70% of nights during a consecutive thirty day period anytime during the first three months of initial usage Must have documented within first three months of therapy, otherwise trial is considered failed Continued coverage begins with the date of reevaluation March Failing the 12 Week Trial Period May re-qualify New FTF re-evaluation by treating physician Determine the etiology of the failure to PAP therapy Repeat sleep test Facility-based setting only Type I study Diagnostic Titration Split-night March Concurrent use of Oxygen with CPAP or Bi-Level Therapy Testing must be done in Chronic Stable State Both oxygen LCD and PAP LCD must be followed OSA sufficiently treated and lung disease unmasked Overnight oximetry during home sleep test not eligible to be used for oxygen qualification. Testing may only occur during a Titration Study and 1. Minimum 2 hours 2. During titration specific reduction in AHI/RDI criteria met 3. Only performed after optimal PAP settings determined 4. Nocturnal oximetry conducted during PSG shows 88% for 5 minutes. March Respiratory Assist Device (RAD) Policy Revision - December 2014 Definition of Central Sleep Apnea and Complex Sleep Apnea now includes CAHI and expands signs and symptoms Severe COPD does not require sleep testing to exclude OSA where clinical picture is detailed PSG testing now includes HST when used in the in-patient hospital setting to establish or rule out OSA March CSA Central Apnea-Central Hypopnea Index (CAHI) CAHI is the average number of episodes of central apnea and central hypopnea per hour of sleep without the use of a positive airway pressure device CompSA CAHI is determined during the use of a positive airway pressure device after obstructive events have disappeared March ACA Section 6407 Implementation vs. Enforcement Implementation Date For all requirements July 1, 2013 Enforcement Date For WOPD requirements Date of Service (DOS) January 1, 2014 For F2F requirements Pending CMS instruction 2015 for the MACS CERT enforcement began with implementation date March Face-to-Face Evaluation Face-to-Face Documentation Beneficiary was evaluated and/or treated for a condition supporting the DME ordered All Medicare coverage and documentation requirements for DMEPOS apply F2F Evaluation must take place within 6 months prior to the date on the written order Must be received by supplier prior to delivery of DME Date stamp (or equivalent) upon receipt March FAQ Question: Does the ordering physician have to be the same physician that conducts the face-to-face evaluation? Answer: No. The physician tha
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