Preventing denials for CPAP devices and accessories

CMS determined the improper payment rate for continuous positive airway pressure (CPAP) devices and accessories was 15% in 2023, with a projected improper payment amount of $157.5 million. For this reporting period, approximately 73.5% of CPAP improper payments were caused by insufficient documentation.

Organizations can view CMS’ provider compliance tip on CPAP devices and accessories for information on proper billing codes, coverage criteria, and documentation tips.

To qualify for CPAP coverage, a patient must have an in-person clinical evaluation by the treating practitioner before the sleep test to assess them for obstructive sleep apnea (OSA). CMS defines “apnea” as a cessation of airflow for at least 10 seconds. It defines “hypopnea” as an abnormal respiratory event lasting at least 10 seconds with at least 30% reduction in the thoracoabdominal movement or airflow and at least 4% oxygen desaturation.

The patient must have an approved sleep test for one of the following:

• Polysomnogram attended by a qualifying practitioner and conducted in a sleep lab
• Unattended home sleep test (HST) with a Type II or III home sleep monitoring device
• Unattended HST with a Type IV home sleep monitoring device that measures at least three channels

An initial 12-week period of CPAP is covered in adult patients with OSA if either of the following criteria are met during the sleep test:

• Apnea-hypopnea index (AHI) or respiratory disturbance index (RDI) greater than or equal to 15 events per hour, with at least 30 events taking place
• AHI or RDI greater than or equal to five, and less than or equal to 14, events per hour, with at least 10 events taking place and documentation of the following:
  
  • Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia
  • Hypertension, ischemic heart disease, or history of stroke

Following this 12-week period, coverage depends on the practitioner’s reassessment and documentation of the patient’s symptoms and therapy regimen adherence.

CMS covers CPAP devices under the durable medical equipment (DME) benefit. DME suppliers and treating practitioners who prescribe CPAP devices and accessories must meet the provisions outlined in National Coverage Determination 240.4. They can find the most up-to-date list of Healthcare Common Procedure Coding System and Current Procedural Terminology (CPT®) codes in Local Coverage Determination L33718.