IDS - HOME SLEEP TESTING CENTRAL
IDS is very excited about the Centers for Medicare & Medicaid Services publishing a National Decision Memo on March 13, 2008 approve unattended home sleep testing using Type II, Type III and Type IV portable testing devices as qualification for CPAP therapy. Other commercial insurers are now starting to follow Medicare lead by introducing similar policies. We feel this will help lower a major barrier in testing and treating many of the millions of undiagnosed Americans who would have refused or otherwise been unable to be tested in a traditional lab setting.
IDS SLEEP - Home Sleep Testing Program
IDS is an Independent Diagnostic Testing Facility will provide a home testing service which utilizes our advanced web based technology infrastructure along with a huge network of DME/HME suppliers, sleep labs, and other providers around the country, so that they may quickly and efficiently courier test equipment to patients in their locale, for whom physicians have ordered our testing service. IDS provides the testing instruction, along with the test equipment (type III or type IV portable device), disposables, 24hr patient phone support, scoring, professional interpretation by accedited physicians, and automated test report distribution to the referring physician.
Our technology infrastructure and unmatched inventory of home sleep testing equipment allows us to provide the most professional, accurate,and effecient service available. Our mail order model allows turnaround in as little as 4-5 days! And soon for patients covered by many commercial insurers, we will introduce our Supplier delivered model, which will allow testing turnaround time in as little 24-48 hours from the physician's order. Compare this turnaround time to weeks and often months with a traditional in-lab model.
If you are a DME supplier, sleep lab, or other provider interested in the IDS Sleep program, you should register for your FREE, NO OBLIGATION IDS account as soon as possible or call 1-800-355-0691. INITIAL AVAILABILITY IS LIMITED by number of devices.
NEWS AND COMMENTARY ON HOME SLEEP TESTING
Due to so much confusion on this subject in the marketplace, in print, and on the web; IDS is dedicating this page to be your 'go to' source with all of the latest news, documents, web links, and commentary on Home Sleep Studies. To get the latest information as it happens, and to ensure a position in the IDS Sleep Program, dont forget to Register for your Free IDS account now for the latest!
Sept 18 , 2008 - BREAKING NEWS: UPDATED DME MAC CPAP LCD's POSTED
The DME Mac Juridstictions posted the September revision of the LCD for Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L11518). Here's the link (this link is for Jurisdiction A)
- Here is the quick summary of changes:
- Revised the definition of Type IV device. They now DO NOT require respiratory effort, and in-fact do not specify the required channels.
- Added alternative Home sleep test instruction method which allows Video Instruction, supplemented by 24hr tech support.
- Relaxed what were much more rigid initial clinical evaluation requirements, and removed some languge about home sleep testing on patients with co-morbid conditions
- Expanded the dates for Re-Evaluation after patient receives CPAP treatment.
- Added a method to requalify patients after failing the initial 90 day period.
- DME suppliers are still not allowed to pick up or deliver the testing equipment.
AUGUST 18 , 2008 - NEWS: DME CPAP LCD's DELAYED, BEING REVISED
So far this morning, DME MAC A & B Regions have sent notification that they are delaying the September 1st implementation dated LCD's: Here is a quote from the notification message: "Some criteria in that policy were to take effect for dates of service on or after September 1, 2008. All criteria with a September 1, 2008 implementation date are being delayed. A revised LCD will be published in the near future and will include a new effective date for those criteria."
IDS has no word yet on which parts are being revised... Stay tuned to this page for the latest.
JULY 22, 2008 - Fee Schedule document published!
Upstate Medicare Division of New York published a Part A-B fee schedule for the G Codes! The payment for G-399 is almost identical to what was previously posted for CPT 95806. Schedule posted here:
G0398 $248.39 $235.97 $271.37
G0399 $191.09 $181.54 $208.77
G0400 $171.99 $163.39 $187.90
JULY 22, 2008 - Trailblazer Part A-B LCD Released:
Trailblazer released a notice of revision to its PSG and Sleep Study LCD. They have added very similar language to the DME MAC CPAP LCD's released previously. THe revision states that HST will be covered for the purpose of determining a diagnosis of OSA when prior to the test: there must be focused clinical evaluation for OSA, high pre-test probability of OSA, and it is reasonable and necessary for the diagnosis of the patient’s condition. They have listed the same requirements for interpretation as the DME MAC LCDs. One new item in this LCD; Medicare considers it unlikely that it will be reasonable and necessary for a patient to have more than one home sleep test in a year. Thile not unexpected, this is the first restriction we have seen of this type. The Trailblazer LCD Applies to Facilities/Physicians in Colorado Part A and Part B, New Mexico Part A and Part B, Oklahoma Part A and Part B, and Texas Part A and Part B, and Virginia Part B.
JULY 17, 2008 - CMC Region C LCD Released, along with others...
Cigna Government Services Region C DME MAC released the first LCD for CPAP this morning on the CMS website. This is big news, as this is the first document regulating coverage for CPAP that includes Home Sleep Testing. Region C covers about 1/3rd or more of the country's medicare population. As of the time this was posting, other LCD's from other regions appeared to be posting with identical language.
There are quite a bit of questions answered in this document, and more questions generated as well. The following is a summary of important points.
- The patient must go through a clinical evaluation for OSA by physician before testing is ordered. This must include documenting symptoms such as snoring, observed apneas, choking or gasping during sleep, etc. Eppworth Sleepiness Scale, and physical traits recorded such as BMI, neck circumference, etc.
- The LCD clarifies a definition for Type IV Device to include respiratory effort, airflow, and oxygen saturation as the three required channels. To our knowledge this excludes EVERY type IV device on the market today.
- All Sleep tests must be interpreted by a sleep physician.
- All beneficiaries who undergo an HST must have face to face instruction by the entity providing the HST. This almost eliminates the possibility of Mail order models that have been presented by several companies.
- The LCD states verbatim, "No aspect of the HST, including but not limited to delivery and/or pickup of the device may be performed by the DME Supplier." This obviously hurts our primary distribution model for sleep devices; but with the recent posting to the federal registry that had similar language, it was not unexpected, and IDS has plans in place to still support a similar model utilizing networks of other qualified agents. More to come soon...
- The 12 week evaluation for CPAP is addressed here in detail. It will require a clinical re-evaluation by a physician, and "objective evidence of adherence to use of the PAP device. Adherence is defined as use of PAP >= 4 hours per night on 70% of nights during a consecutive 30 day period anytime during the first 3 months of initial usage." This makes the use of a PAP device that records compliance data mandatory for CMS Beneficiaries. It also makes tracking of that information very important to physicians and especially DME suppliers. IDS will soon have a web based system in place that will provide remote compliance monitoring of the device with selected CPAP manufacturers, along with reminders, and automated physician reports!
Links to the LCD's are listed here...
July 16 , 2008 - NEW CMS REGION C CPAP LCD - POSTING SOON?
Cigna Government Services, the contractor over Medicare DMEPOS Region C, has posted an article discussing the effective dates for the revised LCD for CPAP, however, the link provided tp view the revised LCD on the CMS site (as of this posting) does not contain the new version. When this LCD revision is available, it will be big news, as this would be the first DME Region to post a local policy for CPAP since the decision memo was posted back in March.
The article does have some interesting points, summarized below. :
- CPAP dispensed before March 13, 2008 must meet CPAP policy requirements from the old LCD that had an effective date of Jan 1, 2008.
- The recently posted Medicare NCD will govern CPAP dispense retroactively to March 13, 2008 through September 1, 2008
- CPAP dispensed after September 1, 2008 must follow the policy requirements in the new LCD to be with and effective date of September 1.
July 6 , 2008 - PART II: Proposed CPAP Reimbursement Rule Change
There is a proposed ruling in the physicians fee schedule posted (large 23mb download) to the federal registry that prohibits the supplier of CPAP or its 'affiliate' (no definition provided) from performing diagnostic testing for the CPAP that they dispense. We feel this may be aimed at we refer to as 'hybrid' lab that dispense CPAP through a seperate legal entity and DME companies that may feel they can perform, or bill for the test. Here are some important quotes from the document from pg 79-80...
"...we believe that the interests of beneficiaries and the Medicare program can be harmed if the provider of a diagnostic test has a vested interest in the outcome of the test itself. In the specific context of this proposed rule, we believe that the individual or entity that directly or indirectly administers the sleep test and/or
provides the sleep test device used to administer the sleep test (referred to hereinafter as the ‘provider of the sleep test’) has a self-interest in the result of that test if that provider, or its affiliate, is also the supplier of the CPAP device. This provides incentive to test more frequently or less frequently than is medically necessary and to interpret a test result with a bias that favors self-interest. " .... "we are proposing to prohibit payment to the supplier of the CPAP device when such supplier, or its affiliate, is directly or indirectly the provider of the sleep test that is used to diagnose a Medicare beneficiary with OSA. "
This proposed ruling could have some complex implications and interpretation. We feel our model fits nicely within the wording of this ruling, as the DME or Sleep Labs that act as couriers of our testing equipment are just that; Couriers/ delivery agents much like UPS. Any testing performed by our IDTF must be previously ordered by a treating physician with no relationship to any party. Further, the courier has no ownership in the equipment, provides no instruction or support to the patient, has no access to data on the device or the test results prior to our facility receiving and independently scoring the test, and they have no influence on the final results of the test. IDS will be commenting and requesting legal opinion on the ruling to ensure tthat we do get further clarity on the issue.
Again this is a proposed ruling with a comment period available until August 29, and implementation likely no sooner than the end of September.
July 6 , 2008 - PART I: NCD for CPAP Posted, Federal Registry Fee Schedule Posted, Hostpital Outpatient reimbursement posted...
Some interesting documents have been posted on the Medicare site since Thursday July, 3rd.
- The NCD 240.4 for CPAP seems to be Official now, with an implementation set for August 4, 2008 for services performed March 13, 2008 or later.
- The July 2008 update to the Physician Fee Schedule, which determines how most IDTF's and Free Standing Sleep Centers will be reimbursed, was published. Zero Relative Value Units (RVU's) are assigned to all the G-Codes for home sleep testing (G0398, G0399, G0400). Further, each has a payment status of 'C', which means 'carrier priced'. We intepret this to mean that for at least the short term, each individual carrier will determine the reimbursement for the test, and this possibly could be adjusted over time. We do not know if a national pricing base will be set in the future. Finally it proposes some additional future rulings within the document, that we are studying very closely from a legal standpoint.
- The July 2008 OPPS Addendum B update posts a Fee Schedule / reimbursement for hospital outpatient procedures for the HST G-codes. Surprisingly, each code has been posted with the same reimbursement schedule! However, the main OPPS update document on page 212-213 states that the payment status is temporary and 'open for comment.' This fee schedule does not affect IDTF's (such as IDS) or Free Standing Sleep labs. The OPPS Addendum B July 2008 reimbursement table is as follows:
||National Unadjusted Copayment
||Minimum Unadjusted Copayment
||* Indicates Change
||Home sleep test/type 2 Porta
||Home sleep test/type 3 Porta
||Home sleep test/type 4 Porta
June 30 , 2008 - IDS Home Sleep Testing Survey
As excitement builds for Home Sleep Testing, IDS has sent out a survey to those that use IDS or have registered for an account with IDS. Response so far has been tremendous! We appreciate your feedback. If you havent already completed our survey, we would love to hear from you as well! Click here to complete the IDS Sleep Survey
June 12 , 2008 - Sleep 2008 Show
Sleep 2008 has ended. All of the buzz seemed to obviously be generated around home sleep testing at the show. The largest crowds gathered for portable testing equipment and the various presentations with opinions and updates about HST. However, no real news emerged. Rumors abounded that reimbursement schedules will be posted by June 13th or 16th for the G-Codes.
June 11, 2008 - Fee Schedule Document
Washington State Dept of Labor and Industries Physician Fee Schedule updated for July 2008 lists the G-Codes for G0398, G0399, and G0400 as with no specific reimbursement; but instead lists that they are paid on an 'As Reported' basis.
June 1 , 2008 - Medicare Issues Mandates to Carriers to add G-Codes
Download Medicare Instruction Guide to Carriers - Interesting Bullet points from the article...
- CMS is instructing carriers/contractors that they must add the G0397 (type 2 HSTdevice), G0398 (type 3 HST), G0999, and G0400 (type 4 HST) codes to their procedure code file and make them retroactively effective for dates of service on or after
March 13, 2008.
- No RVU's / fee schedules are posted in this document...
May 14, 2008 - Little News...
There has been little news on Home Sleep Testing in the last 3-4 weeks. Apparently there is a meeting at CMS sometime in early June that will involve HST, but details are scarce. Also the reimbursements are 'expected' to be posted sometime in July for the new HST G-codes discussed in an earlier post below.
Official CPAP NCD 240.4 has still not been published as of May 14, 2008.
Still no word on NCD Publishing date, or implementation dates, so Home Sleep Testing is still not posted with updated language! FYI - Once the NCD is published, the regional DMERC's LCDs (Local coverage determination) for CPAP must still be drafted and published. These LCDs may also have comment periods involved that could be 30-90 days long.. We no longer have an estimation of likely implementation dates for the CPAP LCD's. We are told that home sleep testing is NOT valid as a qualification for CPAP until the NCD and LCDs for the DMERC regions are published.
MEDICARE POSTS NEW HCPCS CODES FOR HOME SLEEP TESTING! - April 16, 2008: On the "Official update of the HCPCS code system" on the CMS website, NEW temporary 'G-Codes' to use as billing codes for Home Sleep Testing. No fee schedules have been posted as of the release of this update. The temporary codes are defined as follows:
- G0398 - Home sleep test/type II Portable Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart reate, airflow, respiratory effort and oxygen saturation
G0399 - Home sleep test/type III Portable Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation
G0400 - Home sleep test/type IV Portable Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels
Download Zip File of New G-Codes for Home Sleep Testing - Links directly to CMS Site for download.
- G-Codes such as these are issued when there is no CPT code currently available for a service.
These new codes will be a BIG surprise to many, as most thought the existing 95806 CPT code would be used. Further, most thought that Type IV either would not be reimbursed because it did not meed the definition of 95806, or would be billed with a -52 reduced services modifier. It seems obvious now that Medicare will be reimbursing for all device types, each with their own code, and likely their own fee structures.
Also, there are questions concerning the carriers/regions that have already published updated Drafts and Final LCD's for Sleep Testing that are mentioned below in an earlier update... It is our understanding that these new billing codes would invalidate the language added to these LCD's concerning 95806 specifically, and they would need to be revised to include the new procedure codes above.
SLEEP TESTING LCD's UPDATE - April 4, 2008 - Some carriers/regions covering Part A (which covers the labs performing the tests) have begun work to modify the language in their Sleep Testing LCD's to include Home Sleep Studies referencing the 95806 code. The Empire Region has already published their Final LCD, which basically cut and paste the language from the CPAP Decision memo into their LCD that previously covered In-Lab PSG Sleep Testing.
Region III Sleep Testing LCD DRAFT: Covers labs in Pennsylvania, Maryland, District of Columbia, New Jersey, Delaware
- Empire - National Gov Services LCD for Polysomnography and Sleep Studies (L26428) - Covers
labs in Region I, II, III, V, IX
- National Gov. Services
LCD for Polysomnography and Sleep Studies (L26428) - Covers Indiana.
- WARNING: These above Sleep Testing LCD's only apply to the labs performing sleep tests and billing Part A. The updated NCD has not been published for CPAP as yet. Furthermore, the DMERC LCD's will not be published for some time AFTER the NCD is updated. So, until that time, even though labs in the covered regions above may bill for Home Sleep Tests, they will not be valid as qualifying tests for CPAP therapy for Medicare.
Aetna Approves Home Sleep Testing for CPAP - March 14, 2008-
Aetna has approved home sleep testing effictive Immediately. They appear to be following medicare's policy almost to the letter with device types and are using the same research cited by CMS. They also refer to using CPT 95806 for unattended home sleep testing. Here is a link to the coverage policy.
CMS NATIONAL DECISION MEMO ON HOME SLEEP TESTING FOR CPAP - Mar 13, 2008 Decision Memo - Medicare posted the decision for changes to the NCD for CPAP this afternoon. Surprising to the sleep community, Type IV Devices with 3 Channels and the Watchpat 100 device are included. No Implementation date was set. No clarifications were made about the testing itself, as far as certification/accredidation, etc required for performance of the test. No CPT Codes or reimbursements were mentioned for billing for Home Sleep Testing. IDS did not expect these items to be answered here, as this memo is concentrated on the NCD for CPAP which is a DME item. The following is a summary of the changes relevant to Home sleep testing/monitoring.
SUMMARY OF CHANGES
- CPAP for adults is covered when diagnosed using a clinical evaluation and a positive:
A positive test for OSA is established if either of the following criterion using the Apnea-Hypopnea Index (AHI) or Respiratory Distress Index (RDI) are met:
- polysomnography (PSG) performed in a sleep laboratory; or
- unattended home sleep monitoring device of Type II; or
- unattended home sleep monitoring device of Type III; or
- unattended home sleep monitoring device of Type IV, measuring at least three channels
If the AHI or RDI is calculated based on less than two hours of continuous recorded sleep, the total number of recorded events to calculate the AHI or RDI during sleep testing is at least the number of events that would have been required in a two hour period.
We are deleting the distinct requirements that an individual have moderate to severe OSA and that surgery is a likely alternative.
Coverage of CPAP is initially limited to a 12 week period for beneficiaries diagnosed with OSA as subsequently described. CPAP is subsequently covered for those beneficiaries diagnosed with OSA whose OSA improved as a result of CPAP during this 12 week period
- AHI or RDI greater than or equal to 15 events per hour, or
- AHI or RDI greater than or equal to 5 and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke.
CMS / MEDICARE LCD's, NCD's, AND RELATED TO HOME SLEEP TESTING OR CPAP -
- DME MAC LCD Policies for CPAP - PAP devices
- Cigna Government Services AL, AR, CO, FL, GA, LA, MS, NC, NM, OK, PR, SC, TN, TX, VA, VI, WV
- Noridian Administrative Services AK, AS, AZ, CA, Northern Mariana Islands, GU, HI, IA, ID, KS, MO, MT, ND, NE, NV, OR, SD, UT, WA, WY
- National Government Services -Illinois
- NHIC - CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
- Part A - B LCD Policies for PSG - Sleep Studies
INSURANCE COVERAGE POLICIES -
OTHER RELATED ARTICLES AND LINKS (contact us with links to additional articles)
Sleep Review -
HME Today -
Other Online Articles -