In a recent newsletter, National Government Services (NGS) reported on a recent prepayment medical review of claims for continuous positive airway pressure (CPAP) devices.   NGS, the Durable Medical Equipment Medicare Administrative Contractor for Jurisdiction B, reported that the results of the review of 100 claims indicate a claims error rate of 81 percent.

NGS reports that a number of the claims were denied due to one or more of the following most frequent errors:

  • Claims denied due to no documentation received;
  • Claims denied due to no or insufficient medical record documentation of face-to-face clinical evaluation for OSA by treating physician prior to sleep study;
  • Claims denied due to no or insufficient documentation of clinical re-evaluation between the 31st -91st day of therapy with documented improvement of signs and symptoms; and
  • Claims denied due to no or insufficient documentation of adherence to therapy/device usage for four or more hours for 70 percent of a consecutive 30 day period during the first three months of CPAP usage.

A number of other, less frequent errors were also reported.

NGS reports that following a review of the above described findings, their Medical Review department will continue prepayment review of claims for CPAP.  NGS encourages providers to review their local coverage determination (LCD) for Positive Airway Pressure (PAP) Devices for Treatment of Obstructive Sleep Apnea.

Providers who are not located in Jurisdiction B should also consider reviewing their LCD for information on documentation requirements.  Providers can access their LCDs using the Medicare Coverage Database search features.