CPAP/BiPAP

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Physician Documentation Requirements

PAP Devices

05/08/2014

  • Detailed written order that contains:
    • Pt.’s name
    • Detailed description of the item(s) to be ordered
    • Pressure settings
    • Length of Need the Pt. will require the item(s)
    • Physician’s printed name
    • Physician’s NPI
    • Physician’s signature
    • Physician’s date of signature
  • Face to face evaluation dated within 6 months of the detailed written order documenting the Pt.’s diagnosis of OSA or conditions and symptoms that warrant suspicion of OSA
  • Medicare-covered sleep test that meets either of the following criteria:
    • Apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) greater than or equal to 15 events per hour with a minimum of 30 events; OR
    • AHI or RDI greater than or equal to 5 and less than or equal to 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.
  • BiPAPs (E0470)

  • Documentation to meet all of the criteria listed above; AND
  • Documentation that a single level (E0601) positive airway pressure device has been tried and proven ineffective based on a therapeutic trial conducted in either a facility or in a home setting.

Continued Coverage (Beyond the First Three Months of Therapy)

  • Face-to-face re-evaluation by the treating physician between the 31st and 91st day after initiating therapy documenting:
    • The Pt is benefiting from PAP therapy and that symptoms of obstructive sleep apnea are improved, AND
    • Objective evidence of adherence to use of the PAP device reviewed by treating physician.

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