💤 PAP / BiPAP Documentation Checklist
Usage
Use this checklist for all Initial Coverage (Months 1-3), Continued Coverage (Month 4+), and Supply Refills.
1. Initial Coverage (Months 1-3)
Required for first billing of E0601 (CPAP) or E0470 (BiPAP).
Standard Written Order (SWO)
- Basic Elements: Beneficiary Name/MBI, Order Date, Treating Practitioner Name/NPI, and Signature?
- Description: Brand Name/Model or HCPCS code.
- Accessories: Are all separately billable items (mask, tubing, filters) listed individually?
Face-to-Face Clinical Eval
Must be completed prior to the sleep test.
- Symptoms: Documented sleep disordered breathing (snoring, daytime sleepiness, apneas, gasping)?
- Physical Exam: Focused cardiopulmonary/upper airway eval, Neck Circumference, and BMI recorded?
- Epworth Scale: Validated sleep hygiene inventory (e.g., Epworth) included?
Sleep Study (Qualifying Criteria)
Must be FDA-approved and ordered by the treating practitioner.
- AHI/RDI ≥ 15: Covered automatically.
- AHI/RDI 5–14: Covered ONLY with documentation of:
- Excessive daytime sleepiness/insomnia/mood disorders; OR
- Hypertension, ischemic heart disease, or history of stroke.
Additional BiPAP (E0470) Criteria
- CPAP Failed: Documented trial of CPAP (E0601) proved ineffective?
- Was mask fit/comfort addressed?
- Were pressure adjustments tried?
- Switch Rule: If switching < 30 days into trial, no new face-to-face needed. If > 3 months, new face-to-face required (but no new sleep test).
2. Continued Coverage (Month 4+)
Required to continue billing beyond the 3rd month.
- Clinical Re-evaluation: Occurred between Day 31 and Day 91 of therapy?
- Benefit Documented: Note states patient is benefiting (symptoms improved)?
- Adherence (Usage): Objective data download verifies use ≥ 4 hours/night on 70% of nights for any 30-day consecutive period?
- Dr Review: Treating practitioner reviewed the adherence report?
3. Refill Requests (Supplies)
Rules effective Jan 1, 2024.
- Request Date: Contact occurred no sooner 30 days before current supply ends?
- Affirmative Need: Patient specifically confirmed they need the refill (no auto-ship)?
- Functional Condition: For non-consumables, is the dysfunction/damage documented?
4. Delivery & Modifiers
- Delivery Ticket: Includes Brand, Model, Serial #, and Delivery Date?
- Signatures: Signed by patient (or rep) with relationship noted?
- KX Modifier:
- Months 1-3: Applied ONLY if all Initial Coverage criteria met.
- Month 4+: Applied ONLY if both Initial AND Continued Coverage (Adherence) criteria met.
- GA Modifier: Applied if expecting denial (ABN on file)?
5. Replacement & 5-Year RUL
For replacement after the 5-year Reasonable Useful Lifetime (RUL) or due to loss/damage.
5-Year RUL Renewal
- New SWO: Required for the replacement device.
- Face-to-Face Eval: Treating practitioner documents that the beneficiary continues to use and benefit from the device.
- Note: A new sleep test is NOT required if the original qualifying test is on file.
Replacement (Loss, Theft, or Damage)
If replacing < 5 years due to specific incident.
- Incident Documentation: Police report, insurance report, or fire report verifying the specific incident.
- Narrative: Statement detailing the reason for replacement (lost/stolen/destroyed).
6. Beneficiaries Entering Medicare
For patients who had a PAP before joining Medicare and now want coverage.
- Prior Sleep Test: Documentation of a sleep test (completed prior to Medicare enrollment) that meets current Medicare AHI/RDI coverage criteria.
- Clinical Eval (Post-Enrollment): An in-person eval after their Medicare start date where the practitioner documents:
- The beneficiary has a diagnosis of OSA.
- The beneficiary continues to use the PAP device.
- New SWO: A current Standard Written Order for the device.
- A new compliance period is not required