SAN DIEGO-A change in the Centers for Medicare and Medicaid Services’ (CMS’) policy for national carrier determination on coverage for continuous positive airway pressure (CPAP) has created an opportunity for otolaryngologists who want to pursue incorporation of home sleep studies to diagnose obstructive sleep apnea (OSA) into their practices. But there is a limited window of opportunity if physicians wish to ensure their ability to bill for these services, said Pell Ann Wardrop, MD, of Lexington, KY, at the miniseminar, Home Sleep Studies: How Should They Fit into Your Practice?
Explore this issue:December 2009
The comprehensive session, cosponsored by the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Technology Infrastructure Committee, consisted of four presentations to better prepare otolaryngologists who want to step up to the plate and incorporate home sleep studies into their diagnostic armamentaria. The presenters acquainted attendees with the advantages and drawbacks for laboratory polysomnography (PSG) versus portable monitoring; discussed the limitations of home sleep studies (HSS) with portable monitoring devices; noted how HSS limitations affect appropriate patient selection; and offered practical advice regarding sleep medicine certifications and reimbursement. Interactive audience questions provided an adjunct to the session’s content.
Drivers of CMS Policy Changes
First, Dr. Wardrop, who is Chair of the AAO-HNS Sleep Disorders Committee, summarized the CMS reassessment process regarding 240.4, a durable medical equipment ruling that governs payment for CPAP to treat OSA. Until 2005, CMS had maintained that laboratory PSG was the gold standard for diagnosis of OSA and that there was insufficient evidence to warrant home sleep testing.
Three events occurred to trigger a revisit to that ruling, said Dr. Wardrop:
- A March 2006 Institute of Medicine report titled Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem1 maintained that an estimated 50 to 70 million Americans are suffering from some type of sleep disorder, adversely affecting their health and longevity, and called for an expanded workforce and development and validation of existing and new diagnostic and therapeutic technologies.
- Also in 2006, Senn et al.2 published results of a two-week trial of CPAP for patients with high clinical probability of OSA, showing that after four months out, 94% of patients were still using their CPAP, demonstrating the efficacy of CPAP for diagnosis of OSA and reducing the need for PSG.
- CMS changed its direction and began looking at predictive results for diagnosis and treatment. At the Academy’s request, CMS began its reassessment of the 240.4 ruling in 2007, commissioning technology assessments from the Agency for Healthcare Research and Quality (AHRQ) in early 2007 and convening a Medicare Evidence Development and Coverage Advisory Committee (MEDCAC) panel on September 12, 2007. In late December of that year, CMS issued its Proposed Decision Memo, which outlined its policy change. The official memo followed in March 2008.
CMS will now pay for an initial 12-week trial of CPAP for adult patients with an apnea-hypopnea index (AHI) or respiratory disturbance index (RDI) ≥ 15/hour or an AHI between 5 and 15 with comorbidities if the disorder has been diagnosed by one of the following: full attended PSG (Type 1) ≥ 7 channels; Type 2, full unattended PSG ≥ 7 channels; Type 3, limited channel devices (usually 4 to 7 channels); or Type 4, with 1 to 2 channels using oximetry as one of the parameters.