1. The paperwork mountain
Written by: Emily Schnieder, RRT & Bridget Bogle, RRT

2. Paperwork mountain Too Most
Expensive
How insurance plays a role in patient home care
VENTS
Too More
Expensive
BIPAP
Start Least
Expensive
CPAP

3. OBJECTIVES Explain what paperwork is needed for
Insurance authorizations regarding a CPAP device.
Explain insurance qualifications for a CPAP based on Medicare guidelines.
Identify specifications regarding CPAP chart notes
Identify specifications regarding CPAP sleep studies
Identify specifications regarding CPAP prescriptions

4. CPAP Requirement
Medical documentation required before the CPAP set up based upon the Medicare standard

5. CPAP Paperwork breakdown
Simplified, you need to gather THREE documents 1. CHART NOTES 2. SLEEP STUDY 3. PRESCRIPTION 1 2 3

6. 1 Chart notes 1. CHART NOTES from ORIGINAL doctor visit
A. Stating the patients OSA symptoms
a) snoring
b) excessive daytime sleepiness
c) gasping during sleep
AND
B. Stating a recommendation for a sleep study

7. SLEEP STUDY RECOMMENDATION
Example chart notes
OSA SYMPTOMS
SLEEP STUDY RECOMMENDATION

8. 2
Sleep study
1. Apnea Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) > 15 events per hour with a minimum of 30 events total OR 2. The AHI or RDI > 5 and < 14 events per hour with a minimum of 10 events total; along with the charted documentation of: A. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia B. Hypertension, ischemic heart disease, or history of a stroke

9. AHI > 15 EVENTS PER HOUR WITH MINIMUM 30 EVENTS TOTAL
Example sleep study
AHI > 15 EVENTS PER HOUR WITH MINIMUM 30 EVENTS TOTAL

10. Sleep Study

11. 3
Prescription
A Medicare grade prescription - also known as a Detailed Written Order (DWO)
Demographic information – Name / DOB
Description of item(s) ordered
Diagnosis
Length of Need
Physician name & signature
Physician NPI #
Date physician signed the order

12. Example dwo PATIENT DEMOGRAPHIC PHYSICIAN NPI DESCRIPTION 14 20
DIAGNOSIS
LENGTH OF NEED
PHYSICIAN
SIGNATURE
DATE SIGNED

13. review 3 Documents needed BEFORE CPAP set up
1. Original doctor visit chart notes
2. Sleep Study
3. DWO

14. Kick that paperwork over to
PHEW!!!
Kick that paperwork over to
Authorizations!!!

15. Cpap set up Kohll’s protocol for Set ups 1. Review OSA
2. Review Patient’s sleep study & RX
3. Describe the patients device
(Respironics or Resmed)
4. Cleaning & troublshooting
5. Mask fitting
6. Demonstration
7. Paperwork

16. Now what?
CoMpLiAnCe

17. compliance
1. >70 % compliant for >4 hours in a 30 day period 2. Face to Face physician follow up by treating physician A. Symptoms of OSA have improved AND B. Compliance download reviewed
31 – 90 Days

18. Compliance DOWNLOAD example
>70% for >4 HOURS

19. FACE TO FACE COMPLIANCE EXAMPLE
OSA SYMPTOMS
IMPROVED
COMPLIANCE
DOWNLOAD
REVIEWED
STATES TO
CONTINUE

20. REVIEW Compliance IS required 1. 31 – 90 days to complete
2. Face to Face follow up with treating physician
3. >70% compliant for >4 hours in a 30 day period
Kohll’s protocol requires patients signature stating they understand the above.

21. Now what???
BI-LEVEL RESCUE

22. BI-LEVEL RESCUE
Transfer of a patient from CPAP to BI-LEVEL therapy due to the CPAP being ineffective within the initial 90 day trial period of CPAP.
Maintains airway patency during inhalation (IPAP)
Overcomes the physiological dynamics during exhalation (EPAP)
Allows patients to maintain airway stability using lower mean airway pressures

23. Determination for bi-level rescue
1. The patient must have qualified for CPAP therapy and attempted to maintain compliance.
2. CPAP therapy was proven ineffective based on a therapeutic trial conducted either in a facility or in a home setting within the initial 90-day trial period. After exhausting all other measures such as mask and settings changes, one of following must be documented by the Physician:
A. Patient is non-tolerant of CPAP therapy
B. Patient is unable to fall asleep on CPAP therapy
C. Patient threshold has been reached

24. questions

25. references
p+Apnea
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