A Practical Guide for Clinicians and Staff
Basic Coverage Criteria
To qualify for PAP device coverage, your patient must meet these key requirements:
1. Initial Clinical Evaluation
- Must be conducted in-person before the sleep test
- Document sleep-related symptoms, duration, and impact
- Include relevant physical exam findings
2. Qualifying Sleep Test Results (must show either):
- AHI/RDI ≥ 15 events/hour with minimum 30 events, OR
- AHI/RDI 5-14 events/hour with minimum 10 events PLUS documentation of:
- Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; OR
- Hypertension, ischemic heart disease, or history of stroke
3. Device Education
- AHI/RDI ≥ 15 events/hour with minimum 30 events, OR
- AHI/RDI 5-14 events/hour with minimum 10 events PLUS documentation of:
- Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; OR
- Patient/caregiver must receive instruction on proper use and care
Documenting Medical Necessity
Initial Evaluation Documentation
Your clinical notes should include:
1. History
- Snoring, daytime sleepiness, observed apneas
- Choking/gasping during sleep
- Morning headaches
- Duration of symptoms
- Epworth Sleepiness Scale score
2. Physical Exam
- Focused cardiopulmonary evaluation
- Upper airway examination
- Neck circumference
- Body mass index (BMI)
Follow-up Documentation (31-90 days)
Must document:
1. Improvement in OSA symptoms
2. Objective adherence data showing:
- PAP use ≥4 hours per night
- Used on 70% of nights
- During a consecutive 30-day period
Required Testing/Monitoring
1. Sleep Testing Requirements
- Must be FDA-approved device
- Test ordered by treating practitioner
- Conducted by qualified Medicare provider
- Test must be facility-based or home sleep test
- Minimum 2 hours of recording if using total events criteria
2. Adherence Monitoring
- Direct download or visual inspection of usage data
- Written report format
- Must be reviewed by treating practitioner
- Keep in patient's medical record
Common Documentation Errors to Avoid
1. Timeline Mistakes
- Missing initial in-person evaluation
- Late follow-up evaluation (after 91 days)
- Documenting improvement before 31 days
2. Content Gaps
- Incomplete symptom documentation
- Missing physical exam elements
- Failing to document specific improvements
- Incomplete adherence data
3. Testing Issues
- Using non-qualifying sleep test types
- Missing minimum recording time
- Incomplete test interpretation
Practical Documentation Tips
1. Use a Structured Template
- Include all required elements
- Standardize documentation across patients
- Make it part of your EHR workflow
2. Timeline Management
- Schedule follow-up between day 31-90
- Set reminders for data collection
- Track adherence downloads
3. Clear Communication
- Document specific symptom improvements
- Include quantitative measures when possible
- Note any challenges or adjustments needed
4. Supporting Details
- Reference specific sleep test results
- Include actual adherence numbers
- Document patient education provided
Special Situations
1. Switching from CPAP to BiPAP
- Document specific reason for ineffectiveness
- Address mask fit/comfort issues
- Note failed pressure adjustments
2. Replacement Equipment
- Within 5 years: Document loss/theft/damage
- After 5 years: Document continued use/benefit
- No new sleep test required
Remember: Medicare contractors may request documentation at any time. Keep detailed records readily available in the patient’s chart.
3. Don’t include clinical information on the oxygen order/prescription – keep this in the medical record
