📦 PAP Accessories & Supplies Checklist
Usage
Use this checklist for billing masks, tubing, filters, and other accessories (A7034, A7035, A7032, etc.). Updated for New Refill Rules Effective Jan 1, 2024.
1. Standard Written Order (SWO)
Must be received prior to claim submission.
- Beneficiary Info: Name and MBI (Medicare ID)?
- Order Date: Clearly listed?
- Description: Brand/Model or HCPCS narrative for each item?
- Note: Supplies must be listed separately (e.g., “Full Face Mask or A7030,” “Heated Tubing or A4604”).
- Quantity: Frequency/quantity to be dispensed is specified?
- Practitioner: Treating Practitioner Name, NPI, and Legible Signature?
2. Refill Requests (Effective Jan 1, 2024)
Strict requirements for Dates of Service on/after 1/1/24.
☐ Delivered / Shipped Items
- Affirmative Response: Documented proof the patient (or rep) affirmatively responded indicating a need for the refill?
- Note: Auto-ship is strictly prohibited.
- Timing (Contact): Contact occurred no sooner than 30 calendar days prior to expected end of current supply?
- Timing (Shipment): Item shipped no sooner than 10 calendar days prior to expected end of current supply?
- Description: Documented description of each item requested?
☐ Retail / Pick-Up Items
- Signature: Signed delivery slip or itemized sales receipt?
- Location: Receipt indicates items were picked up at the store front?
3. Clinical Requirements for Replacement
Rules for specific scenarios.
☐ Replacement During Capped Rental (Months 4–13)
- Clinical Re-eval: Occurred between Day 31 and Day 91 of therapy?
- Adherence: Objective data proves usage ≥ 4 hours/night on 70% of nights?
- Benefit: Doctor documents improvement in symptoms?
☐ Beneficiary-Owned Device (Medicare Paid)
If Medicare paid for the base device (13 months completed).
- Medical Necessity: Does the base device still meet medical need?
- Essential: Are the supplies essential for the effective use of the device?
- Active Order: Recent order on file (within last 12 months)?
☐ Beneficiary Entering Medicare
Patient had PAP before joining Medicare.
- Prior Sleep Test: Documentation of a qualifying sleep test from before enrollment?
- New Clinical Eval: In-person eval after enrollment verifying diagnosis and continued use?
4. BiPAP (E0470) Specifics
If supplies are for a BiPAP without backup rate.
- CPAP Failure: Documentation that E0601 (CPAP) was tried and proved ineffective?
- Intervention: Interface fit and pressure settings were addressed/adjusted before switching?
5. Delivery Documentation (POD)
- Beneficiary Name: Verified on ticket?
- Delivery Address: Matches patient file?
- Item Description: Detailed description (Brand/Model)?
- Quantity Delivered: Matches order?
- Date of Service:
- Shipped: Date label created or package retrieved.
- Delivered: Date patient physically received item.
- Signature: Signed by patient (or authorized rep) with relationship noted?
Reminder
While the specific “functional condition” note is no longer required for every refill, you must still ensure the patient affirmatively confirms they need the item.