Cues for Coding & Coverage

Transcription

1 Cues for Coding & Coverage Last Updated: September, Table of Contents Introduction 1 Testing Specifications 1 Initial Coverage Criteria 2 Upgrades 4 Continued Coverage 5 RAD Replacements & Repairs 6 Accessories 7 Modifiers 8 Definitions 8 Billing for Respiratory Assist Devices (RADs) Introduction: What are Cues for Coding and Coverage? The National Respiratory Network s Cues for Coding and Coverage have been designed to provide you with guideline information about procedural coding, coverage, documentation and payment with regard to Respiratory Assist Devices. For any item to be covered by Medicare, it must: 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. You must receive a written, signed, and dated order before a claim is submitted to the DME/MAC. If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as not medically necessary. Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider" (42 U.S.C. section 13951(e)). It is expected that the patient s medical records will reflect the need for the care provided. The patient s medical records include the physician s office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available to the DMERC/DMC PRC upon request. Testing Specifications: I. What does RAD encompass? There are two types of respiratory assist devices (RADs) covered by Medicare, E0470 and E0471. E0470 is the HCPCS code for a non-invasive, bi-level, respiratory assistive device without a back-up rate feature. E0471 is the HCPCS code for a non-invasive, bi-level, respiratory assistive device with a back-up rate feature (this product will always be downcoded to either an E0470 or E0601 when treating OSA). II. What are diagnoses may qualify for a RAD? This issue of Cues for Coding & Coverage updated by: Andrea Stark DMEPOS Consultant & Reimbursement Specialist andrea@miravistallc.com There are five medical conditions under which coverage of a RAD may be considered: 1. Restrictive Thoracic Disorders: These patients will have a neuromuscular disease or severe thoracic cage abnormality, COPD must NOT contribute significantly to the patient s respiration difficulties. 2. Severe Chronic Obstructive Pulmonary Disease (COPD): These patients have severe damage to the airways and lungs. OSA and treatment with a CPAP must have been considered and ruled out. 3. Central Sleep Apnea (CSA): Defined as (1) an apnea hypopnea index >5; and (2) central apneas/hypopneas >50% of the total apneas/hypopneas; and (3) central apneas or hypopneas 5 times per hour; and (4) symptoms of either excessive sleepiness or disrupted sleep. 4. Complex Sleep Apnea (CompSA): A form of CSA, CompSA is identified by the presence of central apneas or hypopneas upon exposure to a CPAP or E0470 when obstructive events have disappears. These patients have predominately obstructive or mixed apneas during the diagnostic sleep study occurring at 5 times per hour. With use of a CPAP or E0470, they show a pattern of apneas and hypopneas that meets the definition of CSA described above.

2 5. Hypoventilation Syndrome: A state in which abnormally low amounts of air enter the lungs, resulting in hypoxia (falling oxygen levels in blood) and hypercapnia (increased blood carbon dioxide levels). III. What tests may be used to qualify a patient for a RAD? Depending on the patient s disorder, a qualifying arterial blood gas test (ABG), sleep oximetry test (SAT), polysomnogram (PSG), and /or spirometry test will be required. Under NO circumstances may any of these tests be performed by the DME supplier. Arterial Blood Gas (ABG or ): This test takes a measurement of the partial pressure of gases, including carbon dioxide (noted as PaCO2) in arterial blood. The measurement is reported in mm Hg. Sleep Oximetry Test (SAT): This test measures a patient s arterial oxygen saturation during sleep, generally while breathing their prescribed FI02 (amount of oxygen. The saturation is reported as a percentage. Polysomnograms (PSGs): These tests are used to measure AHI during sleep and must be performed in a facilitybased laboratory. This may be a whole night or split night study. PSG tests must document sleep staging via a 1-4 lead electroencephalogram (EEG), electro-oculogram (EOG), submental electromyogram (EMG) and electrocardiogram (ECG) test. Results must document: airflow, respiratory effort and oxygen saturation by oximetry. Spirometry: This test measures the volume and speed of airflow as the patient inhales and exhales. Initial Coverage Criteria: IV What are the initial coverage criteria for a RAD in months 1-3? For an E0470 or E0471 to be covered, the treating physician must fully document in the patient s medical record symptoms characteristic of sleep-associated hypoventilation, such as daytime hypersomnolence, excessive fatigue, morning headache, cognitive dysfunction, dyspnea, etc. Patient s must be diagnosed with one of the following conditions and meet all of the corresponding coverage criteria for that condition: 1. Restrictive Thoracic Disorders: a. They physician must document that the patient has a neuromuscular disease or a severe thoracic cage abnormality, and b. Test results must show one of the following: i. ABG PaCO2 45 mm Hg (must be performed while the patient is awake and breathing their prescribed FI02), or ii. SAT 88% for 5 minutes of nocturnal recording time (must be performed for a minimum of 2 hours while the patient is breathing their prescribed FI02), or iii. For neuromuscular diseases only: maximal inspiratory pressure is <60 cm H20 or forced vital capacity is <50% predicted. c. Chronic obstructive pulmonary disease (COPD) must not contribute significantly to the patient s pulmonary limitation If all of the above criteria are met, either an E0470 or an E0471 device (based upon the judgment of the treating physician) will be covered for patients with a restrictive thoracic disorder during the first three months of therapy. 2. Severe Chronic Obstructive Pulmonary Disease (COPD): a. OSA and treatment with a CPAP must have been considered and ruled out, and b. Test results must show both of the following: i. ABG PaCO2 52 mm Hg (must be performed while the patient is awake and breathing their prescribed FI02), and ii. SAT 88% for 5 minutes of nocturnal recording time (must be performed for a minimum of 2 hours while the patient is breathing 2LPM or their prescribed FI02, whichever is higher). If all of the above criteria are met, an E0470 device will be covered for COPD patients during the first three months of therapy. 3. Central Sleep Apnea (CSA) or Complex Sleep Apnea (CompSA): a. A complete facility based, attended PSG must be performed that documents both the following: i. That the patient has been diagnosed with CSA or CompSA, and Page 2 of 9

3 ii. The patient must show significant improvement of sleep-associated hypoventilation symptoms with the use of an E0470 or E0471 device (on the settings that will be prescribed for initial use at home), while breathing their prescribed FIO2. 3 If all of the above criteria are met, either an E0470 or an E0471 device (based upon the judgment of the treating physician) will be covered for patients with documented CSA or CompSA during the first three months of therapy. 4. Hypoventilation Syndrome: a. Test results must show both of the following: i. ABG PaCO2 45 mm Hg (must be performed while the patient is awake and breathing their prescribed FI02), and ii. Spirometry = FEV1/FVC 70% and an FEV1 50% of predicted, and b. Test results must also show one of the following: iii. iv. The patients PaCO2 worsens 7 mm HG when the ABG is performed during sleep, or immediately upon awakening, while the patient breathes their prescribed FIO2 (as compared to original ABG performed while awake), or AHI < 5 (PSG shows oxygen saturation 88% for 5 minutes of nocturnal recording time (minimum recording time of 2 hours) that is not caused by obstructive upper airway events. If all of the above criteria are met, an E0470 device will be covered for patients with hypoventilation syndrome during the first three months of therapy. KX Modifier: On claims for months one through three, suppliers must add a KX modifier to codes for equipment and accessories only if all coverage criteria have been met. If exact criteria above are not met, the supplier may submit additional documentation with the claim to justify coverage, but the KX modifier must not be used. V. When is a RAD with Back-Up (E0471) covered? For patients who meet restrictive thoracic disorder and CSA or CompSA RAD coverage requirements, an E0471 may be ordered at the physician s discretion. However, for patients with COPD and hypoventilation syndrome, additional requirements must be met. COPD: In addition to meeting the initial coverage criteria for an E0470, COPD patients must also meet all of the following conditions for an E0471 to be covered: For coverage during the first three months of therapy: o Test results must show both of the following: i. The patients PaCO2 worsens 7 mm HG when the ABG is performed during sleep, or immediately upon awakening, while the patient breathes their prescribed FIO2 (as compared to the original ABG performed while awake), and ii. SAT 88% for 5 minutes of nocturnal recording time (must be performed for a minimum of 2 hours while the patient is breathing 2LPM or their prescribed FI02, whichever is higher). For coverage on day 61 and beyond: i. An ABG performed while the patient is awake and breathing their prescribed FI02 shows PaCO2 52 mm Hg, and ii. While using an E0470, SAT 88% for 5 minutes of nocturnal recording time (must be performed for a minimum of 2 hours while the patient is breathing 2LPM or their prescribed FI02, whichever is higher). Hypoventilation Syndrome: In addition to meeting the initial coverage criteria for an E0470, patients with hypoventilation syndrome must also meet the following conditions for an E0471 to be covered: A covered E0470 is being used, and Spirometry = FEV1/FVC 70% and an FEV1 50% of predicted, and o Test results must also show one of the following: iii. An ABG performed while the patient is awake and breathing their prescribed FI02 shows the patient s PaCO2 has worsened 7 mm Hg, or iv. While using an E0470, AHI < 5 (PSG shows oxygen saturation 88% for 5 minutes of nocturnal recording time (minimum recording time of 2 hours) that is not caused by obstructive upper airway events. Upgrades: Page 3 of 9

4 VI: What is required for a patient to be upgraded from a CPAP (E0601) to a RAD (E0470)? A Bi-Level without backup rate (E0470) will be covered if the patient meets all coverage criteria for a CPAP but finds the CPAP ineffective after a therapeutic trial in a facility or home. If the patient receives a Bi-Level with backup rate feature (E0471) for OSA, it will be downcoded to the least costly, medically appropriate alternative (E0470 or E0601). Defining Ineffective: To switch from an E0601 (CPAP) to an E0470 (Bi-Level), the patient s chart must show that an E0470 is medically necessary and that an E0601 has been tried and proven ineffective. Effective April 1, 2010 documentation must be on file showing that the patient failed to meet therapeutic goals using an E0601 during the titration portion of a facility-based study or during home use, despite optimal therapy (i.e. with a properly fitting mask and appropriate pressure settings). Also effective April 1, 2010, the following must be specifically documented in the patient s chart notes by the physician in order for a CPAP to be deemed ineffective and a Bi-Level to be covered: The beneficiary tried but was unsuccessful with attempts to use the E0601 device; and, Multiple interface options have been tried and the current interface is most comfortable to the beneficiary; and, The work of exhalation with the current pressure setting of the E0601 prevents the beneficiary from tolerating the therapy; and, Lower pressure settings of the E0601 fail to adequately control the symptoms of OSA or reduce the AHI/RDI to acceptable levels. On August 19, 2010, the above physician documentation requirements were revised for claims with dates of service on or after August 1, In order for a patient to be upgraded from a CPAP to a Bi-Level on or after August 1, 2010, the treating physician must specifically document that both of the following issues have been addressed. A. Interface fit and comfort. An appropriate interface has been properly fit and the beneficiary is using it without difficulty. This properly fit interface will be used with the E0470 device; and, B. E0601 pressure settings. The current pressure setting of the E0601 prevents the beneficiary from tolerating the therapy and lower pressure settings of the E0601 were tried but failed to: 1. Adequately control the symptoms of OSA; or, 2. Improve sleep quality; or, 3. Reduce the AHI/RDI to acceptable levels. For complete details on upgrading patients from a CPAP to a RAD, see the Positive Airway Pressure Devices (PAP) Cues for Coding. VII: What is required for a patient to be upgraded from a RAD (E0470) to a RAD with Back-up (E0471)? Depending on diagnosis, the patient may qualify outright for a RAD with back-up according to the physician s judgment. This is true for patients who meet RAD coverage requirements for restrictive thoracic disorder and CSA or CompSA. However, for patients with COPD and hypoventilation syndrome, additional requirements must be met to upgrade to the E0471 which is considered to be a more sophisticated device. Refer to Question V above for detailed criteria on submitting for this change in equipment. If the patient does not meet the additional coverage criteria to qualify for an upgrade, the patient may pay for the upgrade out of pocket if you disclose the additional features of the E0471 and rationale as to why Medicare would consider the E0471 an upgrade. In this scenario Medicare will continue to pay for the lesser level of equipment (presumably the E0470) and the patient must pay monthly for the difference in your retail charges for the two pieces of equipment. When billing these items to Medicare you must bill as follows: DOS HCPCS Mod 1/ Mod 2 / Mod 3 / Mod 4 Monthly Retail Charge 01/01/2010 E0471 RR KH GA $600.00* 01/01/2010 E0470 RR KH KX GK $300.00* *Retail charges vary based on your usual and customary prices. This is presented for demonstration purposes and is not a recommendation as to pricing points. In cases where the customer does not qualify for the E0471, the KX modifier is not used when billing that line item. In the example above the patient would be required to pay an additional $300 out of pocket for each month they choose to keep the higher level equipment. Page 4 of 9

5 Continued Coverage Beyond Month 3: VIII. What is required for continued coverage of a RAD beyond the initial 3-month trial period? The patient must undergo a new face-to-face examination between the 61 st and 90 th day of therapy for continued coverage in months four and beyond. During the exam, the treating physician must assess and document in the patient s medical record 1) the progress of the patient s symptoms and 2) how often they are using the RAD. Compliant usage of a RAD is defined as using the device for an average of 4 hours per 24 hour period. The treating physician must sign and date a statement declaring that the patient is compliantly using the device (an average of 4 hours per 24 hour period) and that the patient is benefiting from its use. Suppliers must maintain a copy of this statement in their files. Previously, a statement of compliant usage from the patient was also required. However, effective 02/01/2010, compliance statements are no longer required from the patient. Medicare will not continue coverage for the fourth and succeeding months of therapy (day 91 and beyond) until the face-to-face exam has taken place and the supplier has received a signed and dated statement from the treating physician. KX Modifier: If you have documentation on file showing the continued coverage criteria above have been met, the KX modifier should be added to claims for months four and beyond. IX. What if the patient is seen late (after 90 days) or physician documentation isn t received timely? If suppliers are not able to obtain a signed and dated statement from the physician in time to bill for months four and beyond, a supplier may hold claims until the patient is seen and the statement is obtained. Once the physician s statement is obtained, if all reports indicate the patient is compliantly using the device and continues to meet coverage criteria, suppliers may submit claims retroactively (the physician s statement only needs to be on file, and does not need to be submitted with the claims). X. What if the patient is not compliant or will not return to see the physician for their follow-up face-to-face visit? If you are aware that the patient will not meet coverage criteria at any time, you may always pick-up your equipment. If the patient wishes to keep the equipment they should sign an Advance Beneficiary Notice (ABN) that clearly explains that the patient is no longer meeting the coverage criteria in terms that the patient can understand. There may be cases where you know an item or service will deny and the patient refuses to sign an ABN and accept financial responsibility. In this case, you should generally refuse to service the patient. However, sometimes refusing service is not an option (i.e. the health of the patient would be put in jeopardy, or the patient already has the equipment and refuses to return it). In this case, it may be possible to execute an ABN even if the patient refuses to sign, so long as certain requirements are met. The following citations provide guidance on refusal to sign ABNs: Chapter 30 of the Claims Processing Manual Section discusses Beneficiary Refusal, Section Discusses the Refund Requirements applicable to DME providers, and Section 150 further details the implementation of the Refund Requirements on DME claims. In order to effectively execute an ABN where the patient refuses to sign, all of the following conditions MUST be met: 1. You must accept assignment. 2. You execute an ABN explaining the specific reason(s) the claim is expected to deny. 3. The patient demands the service but still refuses to sign the ABN or be held financially liable. 4. The patient s refusal is witnessed by the notifier (you) and a second party (this could be via telephone, where the second party is called to witness the refusal while you are on-site). 5 Page 5 of 9

6 If these requirements are met, you should: 1. Include an annotation on the ABN that the patient refused to sign or pay but demanded service. 2. The annotation must be signed by both the notifier (you) and the second witness. 3. This may be included above the empty patient signature line or in the margins of the ABN. 4. File the claim with the GA modifier, stating that an ABN was presented to the patient. According to the instructions, Medicare will hold the patient financially liable and refund requirements will not apply to funds collected from the patient. This is no guarantee that the patient will pay you for services, and your first option should be to retrieve your property when possible. Please note that an unsigned ABN may only be considered valid in cases where you have accepted assignment and expect the claim to deny. These protections do not apply to non-assigned claims. RAD Replacements & Repairs: XI. When is a replacement RAD covered? RADs may be replaced after they reach their reasonable useful lifetime (RUL) of 5-years. However, RADs should not be replaced simply because they have reached their RUL. If a device is replaced after 5-years of use (RUL is based on delivery date, not equipment age), the supplier must be able to provide an explanation of why the device is no longer useable. If a RAD is replaced after reaching its 5-year RUL, a new face-to-face evaluation must take place that documents that the patient has a covered condition and continues to require the use of a RAD. New testing would not be required, and documentation of compliance would not be required for continued coverage beyond the fourth month. However, the patient must have previously documented test results that meet current Medicare requirements at the time of replacement. If these criteria are met, a replacement RAD may be issued and a new 13-month rental period may begin. Patient owned RADs may also be replaced in the event the equipment is lost, stolen or irreparably damaged beyond repair (i.e. fire, flood, etc.). For loss, suppliers should obtain a written explanation from the patient of how the equipment was lost. For theft, suppliers should obtain a copy of the police report. Irreparable damage is rare, and it s important to note that Medicare will not pay to replace equipment damaged by normal wear and tear during its RUL. If a RAD is replaced due to loss, theft or irreparable damage prior to reaching its 5-year RUL, there is no requirement for new testing, or trial period. However, the patient must have previously documented test results that meet current Medicare requirements at the time of replacement. If equipment is replaced due to RUL, loss, theft or irreparable damage, the RA modifier must be appended to the first month s claim, only. A narrative explanation of why the equipment is being replaced must also be included on the claim. Effective January 1, 2009, claims billed with the invalid RP replacement/repair modifier will be rejected. Replacement RADs are also covered for patients enrolling into the Medicare program for the first time, who had a RAD rental under a previous insurer. Note: if you are a non-participating supplier you always have the option to not accept assignment if you suspect Medicare may not pay your claim. If you have reason to suspect that Medicare may not pay the claim, you must disclose your suspicion in terms the patient can understand via an Advance Beneficiary Notice (even if you choose to not accept assignment). In cases where a supplier collects money and is subsequently denied for medical necessity reasons, they are obligated to refund that money to the patient unless an ABN was obtained and properly indicated on the claim. XII. How do I bill for RAD repairs? During the 13-month rental period, payment for repairs and labor are included in Medicare s monthly rental fee and are not separately payable. You must continue to repair and service the patient s equipment as needed, regardless of reimbursement eligibility. If RAD equipment needs to be repaired after a patient s equipment caps out, and the parts are not under manufacturer s warranty, you may bill for both repairs and labor. Repairs: A new order is not required for RAD repairs if you are the original supplier of the RAD equipment. However, if another supplier provided the RAD, the supplier making the repairs must obtain an order to establish the medical necessity of the base equipment. If there is no specific HCPCS assigned to the part repaired, use miscellaneous code E1399. When using E1399, you must include the following in the NTE/narrative record of your claim: A description of the item or part (i.e. replaced damaged blower). Why the repair is medically necessary (e.g. for use with pt owned RAD). The make, model and MSRP pricing of the item or part. Labor should be billed with HCPCS K0739. One unit = 15 minutes of technical labor. Labor charges may not include travel time or service fees. Page 6 of 9

7 Temporary replacement equipment provided for the patient to use during repairs may also be billed. In cases where equipment is removed from the patients home for at least 24 hours, loaner may be provided and billed for with HCPCS K0462. When billing for K0462, you must include the following in the NTE/narrative 7 record of your claim: A description of the item picked up from the patient for service (make, model and HCPCS). A description of the equipment being loaned to the patient (make, model and HCPCS). Payment for the K0462 will be made at the lesser monthly rental allowance for the HCPCS of either the equipment loaned to the patient or the HCPCS of the equipment being repaired. If equipment is being repaired, the RB modifier must be appended to the claim. Effective January 1, 2009, claims billed with the previous replacement/repair RP modifier will be denied. Accessories: XIII. What are the coverage guidelines for RAD accessories/supplies? Accessories used with a RAD device are covered when the coverage criteria for the base equipment (RAD) are met (apply the KX modifier). Accessories are separately reimbursable at the time of initial issue and when replaced. HCPCS codes; E0561, non-heated or E0562, heated humidifiers are covered when ordered by the treating physician for use with a covered RAD device (E0470 or E0471). Accessories delivered in greater quantities than Medicare s allowed amounts will be denied, regardless of documentation. Medicare does allow providers to dispense up to a three month supply at one time. At no time can you dispense more than a three month supply. Dates should never be spanned, and a narrative can be included to reinforce the duration of the supply (most DME MACs see the narrative as an optional element). Automated refills, even with the patient s consent written or otherwise, are not allowed. Patients or caregivers must be contacted directly and must specifically request each refill before new supplies may be delivered. You may make contact with the patient via telephone up to 7 days before the date supplies are expected to be exhausted and should keep a written log of all contact attempts and authorizations to support these efforts in an audit situation. Supplies can be shipped up to 5 days early (when necessary not every shipment). When contacting the patient, consider using an automated calling system. Systems with the right features, such as Med Sage Technologies, can improve compliance and sales at the same time. Table 1: Accessory Codes with Descriptors and Replacement Allowances: HCPCS Code Description Max Replacement Allowance HCPCS Code Description Max Replacement Allowance A4604 Replacement tubing used w/ heated humidifier and has heated wire running the length of the tubing 1 per 3 months A7034 Nasal interface mask or cannula, w/ or w/o head strap 1 per 3 months A7027 Combination mask; 2 piece system w/ separate elements for oral and nasal use 1 per 3months A7035 Headgear 1 per 6 months A7028 Replacement oral cushion for combo oral/nasal mask 2 per 1 month A0736 Chinstrap 1 per 6 months A7029 Replacement nasal pillows for combo oral/nasal mask 2 per 1 month A7037 Replacement tubing, standard 1 per 3 months A7030 Full face mask 1 per 3 months A7038 Disposable filter 2 per 1 month A7031 Replacement full-face mask interface 1 per 1 month A0739 Non-disposable filter 1 per 6 months A7032 Replacement cushion - nasal mask interface that goes around the nose, but not into the nostrils 2 per 1 month A0746 Replacement water chamber for the humidifier 1 per 6 months A7033 replacement pillow - nasal cannula- 2 per 1 month Page 7 of 9

8 type interface Modifiers: KX Append to claims only if all coverage criteria are met. GA Append to claims if coverage criteria are not met, but an ABN is on file (will result in a denial, cost passed on to patient). GZ Append to claims if coverage criteria are not met and no ABN is on file (will result in a denial, cannot be passed on to patient). EY Append to claims if no physician order is on file (will result in a denial, cannot be passed on to patient). Claim lines for RADs and accessories billed without a KX, GA or GZ modifier will be rejected. Rejected claims will need to be corrected and resubmitted for payment. This error cannot be corrected through the reopenings process. Definitions: Apnea cessation or airflow for at least 10 seconds. Apnea-hypopnea index (AHI) average number of apneas and hypopneas per hour of sleep without the use of a positive airway pressure device. Back-up Rate Feature a ventilator that has a timing mechanism to guarantee a minimum respiratory rate to the patient if they fail to sufficiently breathe spontaneously. Central Sleep Apnea (CSA) (1) an apnea hypopnea index >5; and (2) central apneas/hypopneas >50% of the total apneas/hypopneas; and (3) central apneas or hypopneas 5 times per hour; and (4) symptoms of either excessive sleepiness or disrupted sleep. Complex Sleep Apnea (CompSA): A form of CSA, CompSA is identified by the presence of central apneas or hypopneas upon exposure to a CPAP or E0470 when obstructive events have disappears. These patients have predominately obstructive or mixed apneas during the diagnostic sleep study occurring at 5 times per hour. With use of a CPAP or E0470, they show a pattern of apneas and hypopneas that meets the definition of CSA described above. FI02 the fractional concentration of oxygen delivered to the patient for inspiration. For the purpose of this policy, the patient s prescribed FIO2 refers to the oxygen concentration the patient normally breathes when not undergoing testing to qualify for coverage of a Respiratory Assist Device (RAD). That is, if the patient does not normally use supplemental oxygen, their prescribed FIO2 is that found in room air. FVC forced vital capacity Hypopnea abnormal respiratory event lasting at least 10 seconds associated with a 30% reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a 4% decrease in oxygen saturation. Obstructive Sleep Apnea A condition in which five or more apneic periods (of at least 10 seconds each) occur per hour of sleep and characterized by occlusion of the oropharyngeal airway with continued efforts to breath. Diagnosis is confirmed by monitoring the patient during sleep for periods of apnea and lowered blood oxygen levels. Obstructive sleep apnea is caused by obstruction of the upper airways. Physician s Statement a signed and dated statement completed by the treating physician no sooner than 61 days after initiating use of the device, declaring that the patient is compliantly using the device (an average of 4 hours per 24 hour period) and that the patient is benefiting from its use. Polysomnography Continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep with physician review, interpretation, and report. It must include sleep staging, which is defined to include a 1-4 lead electroencephalogram (EEG), and electro-oculogram (EOG), and a submental electromyogram (EMG). It must also include at least the following additional parameters of sleep: airflow, respiratory effort, and oxygen saturation by oximetry. It may be performed as either a whole night study for diagnosis only or as a split night study to diagnose and initially evaluate treatment. Differs from a Sleep Study as the polysomnography includes sleep staging. Sleep Study Continuous and simultaneous recording of physiologic, pathophysiologic parameters of sleep for six or more hours. Results are review, analyzed and interpreted by a physician. Specific parameters that are recorded include: ventilation, respiratory effort, ECG or heart rate, and oxygen Page 8 of 9

9 saturation, either attended or unattended by a technologist. Continuous Positive Airway Pressure (CPAP) device(e0601) delivers a constant level of positive 9 air pressure (within a single respiratory cycle) by way of tubing and a noninvasive interface (such as a nasal, oral, or facial mask) to assist spontaneous respiratory efforts and supplement the volume of inspired air into the lungs. Respiratory Assist Device (RAD) without backup rate (E0470) delivers adjustable, variable levels (within a single respiratory cycle) of positive air pressure by way of tubing and a noninvasive interface (such as a nasal, oral, or facial mask) to assist spontaneous respiratory efforts and supplement the volume of inspired air into the lungs A RAD with backup rate (E0471) delivers adjustable, variable levels (within a single respiratory cycle) of positive air pressure by way of tubing and a noninvasive interface (such as a nasal or oral facial mask) to assist spontaneous respiratory efforts and supplement the volume of inspired air into the lungs. In addition, it has a timed backup feature to deliver this air pressure whenever sufficient spontaneous inspiratory efforts fail to occur. This Cues for Coding & Coverage Brought to You By: For questions regarding the information contained within this publication, please contact: Kelly Riley CRT, RCP Director, National Respiratory Network kriley@medgroup.com Page 9 of 9