01-010 Replacement PAP Device Supplies and Accessories Notification of Medical Review

Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare & Medicaid Services (CMS), is conducting post-payment review of claims for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) services billed on dates of service from January 1, 2017, through December 31, 2017. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request letter, and resources providers may wish to consult when submitting claims.

Background

Medicare covers replacement supplies for positive airway pressure (PAP) devices only when suppliers document that the supplies remain reasonable and necessary. Previous Office of Inspector General (OIG) reviews found that Medicare allowed replacement of PAP device supplies more frequently than was reasonable and necessary and that durable medical equipment (DME) suppliers often did not have the documentation required to support the need for replacement supplies.

According to OIG report A-04-17-04056: “Most Medicare Claims for Replacement Positive Airway Pressure Device Supplies Did Not Comply with Medicare Requirements” dated June of 2018, of the 110 claims in the stratified random sample, 86 did not comply with Medicare requirements. Based on these results, the OIG estimated that Medicare made overpayments of an estimated $631.3 million for replacement PAP device supply claims that did not comply with Medicare requirements.

Reason for Review

In response to the OIG report, the CMS tasked Noridian, as the SMRC, to perform data analysis and conduct medical review.  Noridian will complete medical record review to determine if suppliers billed in accordance with statutory, regulatory and subregulatory guidance.

Claim Sample Detail

HCPCS
  • A4604: Tubing with integrated heating element for use with positive airway pressure device
  • A7027: Combination oral/nasal mask, used with continuous positive airway pressure device, each
  • A7028: Oral cushion for combination oral/nasal mask, replacement only, each
  • A7029: Nasal pillows for combination oral/nasal mask, replacement only, pair
  • A7030: Full face mask used with positive airway pressure device, each
  • A7031: Face mask interface, replacement for full face mask, each
  • A7032: Cushion for use on nasal mask interface, replacement only, each
  • A7033: Pillow for use on nasal cannula type interface, replacement only, pair
  • A7034: Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap
  • A7035: Headgear used with positive airway pressure device
  • A7036: Chinstrap used with positive airway pressure device
  • A7037: Tubing used with positive airway pressure device
  • A7038: Filter, disposable, used with positive airway pressure device
  • A7039: Filter, non-disposable, used with positive airway pressure device
  • A7046: Water chamber for humidifier, used with positive airway pressure device, replacement, each

Access related project details below.

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review. Documentation requested has been made specific to assist the provider in collecting and submitting pertinent information to decrease provider burden.

  1. Valid physician or non-physician practitioner order for the PAP supplies and accessories billed
  2. Medical record documentation to support the beneficiary’s continued need for PAP device or PAP device supplies and accessories
  3. Timely refill request documentation for each accessory or supply billed
  4. Proof of delivery showing sufficient content to identify the beneficiary’s receipt of each supply or accessory billed
  5. Legible handwritten or valid electronic signature and signature log, if acceptable
  6. Advance Beneficiary Notice of Noncoverage (ABN), if applicable

References/Resources

  • Title XVIII of the Social Security Act, §1862(a)(1)(A). Exclusions from Coverage and Medicare as Secondary Payer
  • Title XVIII of the Social Security Act, §1879(a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
  • 42 CFR 424.57(c)(12). Supplier Must Maintain Proof of Delivery
  • Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8. No Response or Insufficient Response to Additional Documentation Requests
  • Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4. Signature Requirements
  • Publication 100-08, Medicare Program Integrity Manual, Chapter 4, Section26. Supplier Proof of Delivery Documentation Requirements
  • Publication 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26.1. Proof of Delivery and Delivery Methods
  • Publication 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26.3. Proof of Delivery Requirements for Recently Eligible Medicare FFS Beneficiaries
  • Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.1. Physician Orders
  • Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.2. Verbal and Preliminary Written Orders
  • Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section2.3. Detailed Written Orders
  • Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.4. Written Orders Prior to Delivery
  • Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.7. Requirement of New Orders
  • Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.8. Refills of DMEPOS items provided on a Recurring Basis
  • Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.7. Documentation in the Patient’s Medical Record
  • Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 8. Supplier documentation and Proof of delivery
  • Local Coverage Determination (LCD) L33800: Respiratory Assist Devices. Effective 10/01/2015-present
  • Local Coverage Determination (LCD) L33718: Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea. Effective 10/01/2015-present
  • Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs. Effective 01/01/2017-present
  • Local Coverage Article A52467: Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea. Effective 10/01/2015-present
  • Local Coverage Article A52517: Respiratory Assist Devices. Effective 10/01/2015-present

 

Last Updated Feb 20, 2019