Sleep & Respiratory. Qualifying Criteria Guidebook

Transcription

1 Sleep & Respiratory Qualifying Criteria Guidebook

2 Sleep & Respiratory Qualifying Criteria Guidebook

3 Respiratory Therapy Services & Equipment Respiratory Care Practitioners at HME are industry top performers in sleep therapy compliance and clinical outcomes monitoring. We provide high quality respiratory care in the home, with extra emphasis on patient education and compliance. Our focus CPAP/BIPAP/APAP/VPAP Adapt/Auto SV Home Ventilators Nebulizers Aerosol Compressors Apnea Monitors Home and Portable Oxygen Systems Pulse Oximeters Suction Machines Cough Assist NOTE: Regarding all the sleep and respiratory guidelines contained within the following pages of this booklet: these are Medicare s current guidelines, and as such are subject to change without notice.

4 Kris Clarksen RRT Years of Experience: 20 Mary Gallegos Sleep & Respiratory Assistant Connie Hardrath RRT, RPSGT Years of Experience: 21 Sandra Jensen CRT Years of experience: 20 Bob Sackett RRT Years of Experience: 2 roberts@hmehomemedical.com Sheila VanCuyk CRT, NPS Years of Experience: 34 shieila@hmehomemedical.com

5 Jeni VanderLogt RRT Years of Experience:11 Molly Warpinski RRT Years of Experience: 6 molly@hmehomemedical.com Nicole Whiters RRT, RPSGT Years of Experience: 15 nicole@hmehomemedical.com

6 Qualifying Criteria per Medicare Guidelines for CPAP/APAP (E0601) for Patients Diagnosed with Obstructive Sleep Apnea Initial face to face appt. w/md prior to sleep study Complete Facility based PSG performed or MC approved home sleep study AHI 5-14 w/documentation of Excessive daytime sleepiness, Hypertension, mood disorder, impaired cognition, Insomnia, history of Stroke, or Ischemic Heart disease OR AHI 15 or greater Pt DOES qualify per Medicare guidelines, ok to call HME to be set up with CPAP/APAP therapy Patient must follow up with their doctor days after starting therapy to establish compliance

7 ICON Auto Offers both CPAP and APAP therapy along with the comfort of thermosmart and SensAwake technology. S9 Series CPAP/APAP Flow Generator Offers both CPAP/APAP therapy along with Climate Control and Easy-breathe Technology.

8 Qualifying Criteria per Medicare Guidelines for BIPAP (E0470) for Patients Diagnosed with Obstructive Sleep Apnea Initial face-to-face appt with medical doctor prior to sleep study Complete facility based PSG performed AHI 5-14 w/documentation of Excessive Daytime Sleepiness, Hypertension, Mood Disorder, Impaired Cognition, Insomnia, History of Stroke or Ischemic Heart Disease OR AHI 15 or greater A CPAP has been tried and proven ineffective based on trial either in the lab or in the home (example: AHI still elevated, sleep quality still poor, symptoms of OSA not controlled) Mask interface fit is good If all the criteria above has been met, patient DOES qualify per MC guidelines, ok to call HME ****Please note patient must follow up w/md no sooner than 61 days after starting therapy and a RAD form must be filled out by the MD establishing compliance and noting the patient is benefitting from the therapy.

9 Initial Qualifying Criteria per Medicare Guidelines for BIPAP (E0470) for Patients Diagnosed with COPD ABG s (PaCO2) done while patient awake breathing their prescribed FiO2 is > 52 mmhg Sleep oximetry demonstrates Oxygen Saturations < 88% for > 5 minutes of NOC recording time (minimum 2 hrs recording time) done while breathing Oxygen at 2 Lpm or the patient s prescribed FiO2 (whichever is higher) Prior to initiating therapy, OSA and treatment w/cpap has been considered and ruled out If all of the above criteria have been met, patient DOES qualify per MC guidelines ok to call HME ***Please note patient must follow up with medical doctor no sooner than 61 days after starting therapy and a RAD form must be filled out by the MD establishing compliance and noting the patient is benefitting from the therapy.

10 Qualifying Criteria per MC Guidelines for BIPAP ST (E0471) for Patients Diagnosed with COPD (For patients prescribed an E0471 anytime after INITIAL use of BIPAP [E0470]) ABG s (PaCO2) done while awake and breathing the patient s prescribed FiO2 shows that the patient s PaCO2 worsens > 7 mmhg compared to the original PaCO2 s done prior to starting therapy A facility based PSG demonstrates Oxygen Saturations < 88% for > 5 minutes of NOC recording time (minimum 2 hrs recording time) done while using a BIPAP (E0470) that is NOT caused by OSA If all of the above criteria have been met, patient DOES qualify per MC guidelines ok to call HME ***Please note patient must follow up with medical doctor no sooner than 61 days after starting therapy and a RAD form must be filled out by the MD establishing compliance and noting the patient is benefitting from the therapy.

11 Qualifying Criteria per MC Guidelines for E0471 for Patients Diagnosed with COPD (For patients prescribed an E0471 NO SOONER THAN 61 DAYS after initial start of BIPAP [E0470]) ABG s (PaCO2) done while awake and the patient is breathing their prescribed FiO2 still remains > 52 mmhg Sleep oximetry while breathing with the BIPAP (E0470) device demonstrates Oxygen Saturations < 88% for > 5 minutes of NOC recording time (minimum of 2 hrs recording time) done while breathing Oxygen at 2 Lpm or the patient s prescribed FiO2 (whichever is greater) If all of the above criteria have been met, patient DOES qualify per MC guidelines ok to call HME ***Please note patient must follow up with medical doctor no sooner than 61 days after starting therapy and a RAD form must be filled out by the MD establishing compliance and noting the patient is benefitting from the therapy.

12 Qualifying Criteria per Medicare Guidelines for BIPAP (E0470 or E0471) for Patient Diagnosed with Central/Complex Sleep Apnea Initial face-to-face appt. with medical doctor prior to sleep study Complete facility based PSG performed Diagnosis of Central/Complex Sleep Apnea (Defined as: AHI >5, Central apneas/hypopneas >50% of the total apneas/hypopneas, Central apneas or hypopneas > 5 times per hour, symptoms of either excessive sleepiness or disrupted sleep) Significant improvement of the sleep associated hypoventilation with the use of either E0470 or E0471, documented while breathing the patient s prescribed FiO2 If all of the criteria above have been met, patient does qualify per MC Guidelines OK to call HME for set-up ***Please note patient must follow up with medical doctor no sooner than 61 days after starting therapy and a RAD form must be filled out by the MD establishing compliance and noting the patient is benefiting from the therapy.

13 VPAP Adapt S9 Series Used to treat patients diagnosed with Central Sleep Apnea, Complex Sleep Apnea and Periodic Breathing. Offers Climate Control and Easy-Breath technology.

14 Qualifying Criteria per Medicare Guidelines for BIPAP ST/AVAPS for Patients with Restrictive Thoracic Disorders There is clinical Documentation in the patient s medical record of Neuromuscular Disease or severe thoracic cage abnormality ABG s (PaCO2) done while awake and breathing the patient s prescribed FiO2 is > 45 mmhg OR Sleep oximetry proves Oxygen saturations < 88% for > 5 minutes of NOC recording time (minimum recording time of 2 hrs) done while patient breathing their prescribed FiO2 OR For Neuromuscular Disease (only) Maximal Inspiratory Pressure <60 cmh20 OR FVC is < 50% of predicted COPD does NOT contribute significantly to the patient s pulmonary limitations If all of the above criteria has been met, patient DOES qualify per MC guidelines ok to call HME ***Please note patient must follow up with MD no sooner than 61 days after starting therapy and a RAD form must be filled out by the MD establishing compliance and noting the patient is benefitting from the therapy.

15 Qualifying Criteria per Medicare Guidelines for BIPAP (E0470) for Patients Diagnosed with Hypoventilation Initial ABG s (PaCO2) done while awake and breathing the patient s prescribed FiO2 is > 45 mmhg Spirometry shows FEV1/FVC > 70% and an FEV1 > 50% of predicted Initial ABG s (PaCO2) done during sleep or immediately upon awakening and breathing the patient s prescribed FiO2 shows the patient s PaCO2 worsened > 7 mmhg compared to the original result OR A facility based PSG demonstrates O2 Saturations < 88% for > 5 minutes of NOC recording time. (Minimum recording time 2 hrs) that is NOT caused by obstructive upper airway events (I.E. AHI < 5) If all of the above criteria has been met, patient DOES qualify per MC guidelines ok to call HME ***Please note patient must follow up with medical doctor no sooner than 61 days after starting therapy and a RAD form must be filled out by the MD establishing compliance and noting the patient is benefitting from the therapy.

16 Qualifying Criteria per MC guidelines for AVAPS/BIPAP ST (E0471) for Patients Diagnosed with Hypoventilation A covered BIPAP (E0470) is currently being used Spirometry shows and FEV1/FVC > 70% and FEV1 > 50% of predicted ABG s (PaCO2) done while awake, breathing the patient s prescribed FiO2 shows the patient s PaCO2 worsens > 7 mmhg compared to the original ABG results performed to qualify the patient for the BIPAP (E0470) device OR A facility based PSG demonstrates O2 saturations < 88% for > 5 minutes of NOC recording time (minimum recording time of 2 hrs) that is not caused by obstructive upper airway events (I.E. AHI < 5) If all of the above criteria has been met, patient DOES qualify per MC guidelines ok to call HME ***Please note patient must follow up with medical doctor no sooner than 61 days after starting therapy and a RAD form must be filled out by the MD establishing compliance and noting the patient is benefitting from the therapy.

17 AVAPS Flow Generator Used to treat patients diagnosed with Restrictive Thoracic disorders, Respiratory insufficiency, OSA, Central Sleep Apnea, Hypoventilation Syndrome and COPD

18 Qualifying Criteria per Medicare Guidelines for Oxygen Therapy Oxygen Saturations done in doctor s office within 30 days of ordering O2 OR Oxygen Saturations done in Hospital or Nursing Home within 48 hours of discharge Oxygen Saturations < 88% resting on room air OR If > 88% Oxygen Saturations can be done w/activity while on Room Air Oxygen Saturations must then be done on O2 proving Saturations remain > 88% Patients on Medicare must follow up with their doctor within 90 days of their one year anniversary date for Oxygen therapy Emergency room and nursing home saturations do NOT Qualify per Medicare guidelines for Oxygen therapy Patients requesting tanks smaller than E tanks must get an order from their doctor requesting a conserver trial. Patients on more than 3 Lpm are NOT candidates for conservers. For patients requiring 4 Lpm or more please call HME for detailed MC guidelines

19 HME Sleep & Respiratory offers the latest in Oxygen Technology to ensure that our patients are comfortable both in the home, and while they travel.

20 HME HOME MEDICAL I N S U R A N C E C O N T R A C T L I S T Partial list of contracted carriers, as of 09/26/13. HME facilitates payments with hundreds of payors.this insurance list is subject to change. HME IS a provider for: Aetna only with HealthEOS networks Anthem Blue Cross Blue Shield Arise Auxiant Care Improvement Plus Coalition America Network Cypress Group Health Cooperative Eau Claire Health EOS Multiplan Network HIRSP (WI State Risk Sharing Plan) Homelink HPS Health Payment Systems Medicaid Care Wisconsin First Children s Community Health Plan Community Connect Forward Health Lakeland Care MHS Managed Health Plan UHC Community Plan MSC Care Mgmt Network Health PHCS Savility Network PMCS Professional Medical Claim Solutions Network Prairie States Prevea Health Network Prevea 360 (exclusive) TRPN Three Rivers Provider Network Tricare and ChampVA Trilogy Network Medicare Advantage Plans AARP Medicare Complete Advantage by MHS Aetna Medicare Open Plan Anthem BCBS Medicare Advantage Health Net Medicare icare Independent Care Health Plan Network Platinum Plus & Special Needs Pyramid/Today s Options UHC Dual Complete United HealthCare Medicare HME is NOT a provider for: CIGNA (we may provide if a Multiplan Network PPO) GEHA HUMANA and any ChoiceCare related plans Michigan Medicaid Molina Health Care (formerly ABRI) UMR Aurora Groups WPS Statewide Network

21 Wisconsin counties covered by HME: Brown Dodge Door Calumet Florence Fond du lac Forest Kewaunee Langlade Manitowoc Marinette Menominee Oconto Oneida Outagamie Ozaukee Shawano Sheboygan Washington Waupaca Waushara Winnebago Vilas GREEN BAY 2021 Riverside Dr Green Bay, WI Hours of Operation: Mon - Fri: 7:30am - 6:00pm Sat: 9:00am - 1:00pm SHEBOYGAN 1338 N Taylor Dr Suite A Sheboygan, WI Hours of Operation: Mon - Fri: 8:00am - 5:00pm (Emergency services available after hours) HME Home Medical. 09/13