CMS Reimburses Sleep Apnea CPAP Treatment When Diagnosed with Home Testing

Patients may also not want to undergo testing in a sleep center because they need to take care of their children or an elderly parent, are not close to a center, or simply do not like the idea of sleeping away from home, said Dr. Wardrop.

Costs and Reimbursement

Costs and reimbursement are other factors otolaryngologists need to be aware of when considering sleep testing for their patients.

Up-front costs of PSG are high compared with home testing, said Dr. Davidson. The initial cost of PSG equipment is around $50,000, and it requires renting office space and hiring a technician for every two beds. Technician salaries are generally $40,000 to $50,000 a year, he said.

In contrast, home sleep test machines cost $5000 to $7000. Normally, a nurse or medical assistant can teach patients to use the machine, so hiring new staff is not necessary, said Dr. Davidson. Each test also requires disposables such as nasal cannulae and batteries, which are other costs to consider, he said.

Nancy Collop, MD

Insurance companies normally cover PSG with proper authorization, whereas some companies cover home sleep testing, added Dr. Davidson. In the best markets, reimbursement is $2000 for PSG and $500 for home testing, while in tighter markets, these figures are generally $1000 and $250, respectively, he said. As people ask for home tests, more and more insurers will cover it, he said.

Coverage depends on the region of the country the patient is in and on the insurer, said Dr. Wardrop.

CMS reimbursement for PSG is about $1000, noted Dr. Collop, whereas reimbursement for home monitoring is anticipated to be about $250.

CMS reimbursement for home testing remains a gray area, said Dr. Wardrop. The CMS ruling states that it will pay for CPAP based on a home testing diagnosis; however, the ruling does not say it will pay for home testing, she explained.

It’s only assumed that CMS will pay for it, she said, adding that billing codes still need to be established. We’re gone ahead and have sent in claims to see what CMS will do, she said. It may require an appeal. For type III home testing, we have been told that CMS will likely pay about $200 for the technical and professional component combined, she added.

Another unknown is whether CMS will reimburse for interval home testing during staged surgery for sleep apnea, said Dr. Weaver.

One factor that may affect reimbursement at some point is that some practitioners are asking CMS to cover only those physicians who can read the raw data generated by home testing, said Dr. Weaver. Others are pushing for only sleep physicians certified by the American Board of Medical Specialties to be eligible for reimbursement, he said, adding that this requirement is not in the CMS ruling.