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From the Reimbursement Team: Respiratory Suppliers: We have the scoop!

An MLN article was finally released explaining the expectations of DME suppliers for CPAP accessories. CMS released an article on the subject a few weeks ago; however, we had to wait for further direction from the DME MACs to know how the claims needed to be processed.

The change is due to the DMEPOS industry changing with competitive bid and lower reimbursements, and beneficiaries are struggling to find DME suppliers to get replacement accessories due to documentation being unattainable from the original supplier.

Please note this applies ONLY to the PAP and RAD medical policy for accessories AND where Medicare paid all 13 months of the capped rental period for the base equipment. Claims for beneficiary-owned CPAP or RAD devices require the medical record to show continued medical need, the detailed written order and continued use (refill requirements).

If a review is performed on PAP/RAD accessories, a supplier needs to provide the documentation from the medical record to show continued medical need. Basically, the initial documentation (face-to-face prior to sleep study, sleep study, WOPD, etc.) to support the need of the base equipment will not be requested in a review. Under the new rule, continued medical need is required. Remember, this means it is documentation from the treating practitioner within the preceding 12 months. The documentation needs to show that the beneficiary is benefiting from use, and accessories are needed to maintain proper function of the equipment and to meet beneficiary’s medical need. Also, make sure there is a current detailed written order that includes the accessories being ordered and the refill requirements have been met.

If Medicare did not pay for the base equipment initially, then this new rule does not apply. The supplier would need to follow the normal coverage criteria and requirements in the medical policy (LCD).

The new rule went into effect July 1, 2016, with an implementation of November 2, 2016. Reach out to me with questions.

Ronda Buhrmester, CRT
ronda.buhrmester@vgm.com
O: 888.665.6518