Pulmonology Coding Alert

Watch for more treatment criteria from CMS on the horizon.

While some of Medicares sleep study guidelines are becoming more flexible, stay on guard for requirements that may soon tighten up more than you might like.

Anticipate Stepped-Up Patient Compliance Notes

Expect to see Medicare demanding more objective criteria that the patient is using prescribed therapy, such as CPAP (E0601, Continuous airway pressure [CPAP] device), consistently, predicts Robert Basner, MD, director of the Columbia University Cardiopulmonary Sleep and Ventilatory Disorders Center in New York, N.Y. You may see Medicare asking for documentation within a limited time frame that the patient is compliant in using his prescribed bilevel (E0471, Respiratory assist device, bi-level pressure capability &) or CPAP device (for instance, for four hours per night four times per week -- the standard for documenting patient compliance).

Expect to Substantiate Treatment Benefits

Dont be surprised if Medicare also starts pushing pulmonologists harder to document efficacy of treatments such as CPAP, says Basner. In the past, if patients met a certain apnea or hypopnea threshold, they qualified under Medicare for CPAP, adds Jill M. Young, CPC-ED,CPC-IM, president of Young Medical Consulting LLC in East Lansing, Mich. Now, Medicare is instituting a trial period to determine whether the therapy is working for the patient. The problem is theres no clear measure to gauge effectiveness, leaving doctors wondering what approaches theyll need to find to document success and keep their patients on the therapy, Young says.

Watch out: Given questions about patient compliance and treatment efficacy and the increasing volume of sleep studies, its no wonder why polysomnography is on the Office of the Inspector Generals (OIGs) watch list again this year. For more on this topic, read Protect Your Sleep Study Pay by Minding These Documentation Essentials in Pulmonology Coding Alert, Vol. 10, No. 3.