Medicare And Sleep Apnea Devices

Is surgery the only option for treating sleep apnea or snoring

I do predominantly the line share of sleep apnea surgery in our department. I collaborate closely with the pulmonologists, who are the sleep medicine s. Those are the s that help diagnose and treat sleep apnea, as well. If those patients fail their, their medical or their conservative therapy, that's typically when they get sent to see me for surgical considerations to, to look at potential cures for their apnea. It's not uncommon for me to see a lot of patients for, who come in for snoring complaints and, you know, are wondering whether or not they have sleep apnea. So sleep apnea is condition where you actually stop breathing at night.

Snoring is somewhere on that spectrum, towards the more mild, you know, milder end of that spectrum. But, you know, really the only way to determine if you have sleep apnea, the gold standard of testing, is really getting a sleep study. And that's an overnight, monitored study where patients, you know, sleep in a room that's similar to a hotel room but they're being monitored and they're hooked up, you know, for sound so to speak with different monitors and cables on them. And that's really our best test to diagnose sleep apnea. The treatment for sleep apnea is typically a nonsurgical therapy; something called CPAP,

which stands for Continuous Positive Airway Pressure. And it's the patients that don't tolerate their CPAP who end up seeing me for surgical considerations. And there's a number of reasons why patients may not tolerate their CPAP. But there are some surgeries that can be helpful in patients who are not tolerant of their medical therapy. And I offer a variety of surgeries including nasal surgery, a variety of palatal surgeries for the kind of tonsil and soft pallet region and then also a variety of tonguebased procedures, as well. But we typically see a patient back after their procedure in about three weeks to recheck everything, make sure that they're healing okay.

After that, I normally recheck a sleep study in about three months after their surgery, just to give everything a chance to heal and to scar. And we, you know, make further recommendations based on the result of their followup sleep study after their surgery. We're exploring the, a new technology now which is actually a nerve stimulator for sleep apnea. It's an implantable device, very similar to a pacemaker that goes into the patient's chest. And there's an electrode that will actually stimulate the nerve that goes to the tongue to provide the tongue with a little bit of more tone when they're sleeping at night, and thereby eliminating their sleep apnea.

Medicare Minute Oxygen Testing and Chonic Stable State

Hello and welcome to another edition of MedicareMinute. I'm Robert Hoover, medical director at CGS Administrators, the Jurisdiction CDME MAC. Today I'm going to talk the policy requirements for oxygen testing. To understand Medicare's policy for oxygen,one must first understand the underlying research for the coverage requirements. In 1980 theNocturnal Oxygen Therapy Trial Group led by Tom Petty published the result of a studylooking at stable, chronic obstructive pulmonary disease or COPD patients. This multicenterstudy randomized over 200 patients to either nocturnal oxygen or continuous oxygen andfollowed the patients for at least 12 months.

This seminal study found that patients whoused nocturnal oxygen only were almost 2 times more likely to die than those who used oxygencontinuously. To enroll patients for the study, the researchersdeveloped a set of criteria upon which to evaluate patients for participation. Thoseinclusion criteria are shown on the screen now. The medical community was shocked at the outcomeof the NOTT study. This study clearly demonstrated that continuous oxygen use helped patientwith chronic lung diseases like COPD live longer. And almost 35 years later, oxygenis still the ONLY therapy for COPD that has

been shown to prolong life. Do these look familiaré Not only are theythe Medicare coverage criteria for oxygen but they're the same criteria from the NOTTstudy shown just a few moments ago! Medicare adopted the NOTT inclusion criteria as theMedicare coverage criteria for oxygen therapy. So how did the NOTT results influence Medicare'scoverage requirementsé First Medicare limited coverage to patientswith significant hypoxemia in the chronic stable state. As defined in the Medicare nationalpolicy, chronic stable state is when a patient is not experiencing a period of acute illnessor an exacerbation of their underlying disease.

This requirement mirrors the patients selectedfor the NOTT study. Second, to qualify for oxygen Medicare requiresthat the patient have a severe, underlying chronic lung disease such as COPD or diffuseinterstitial lung disease. Note that there is no mention in the examples of acute conditionslike pneumonia or an undefined hypoxia. Coverage is limited to patients with a severe, chronicunderlying lung disease, again matching the patient population of the NOTT study. Finally, Medicare does not allow oxygen prescriptionsfor Oxygen PRN or Oxygen as needed.As demonstrated in the NOTT study, oxygen

therapy must be used on a continuous basisfor the patient to get the benefit of oxygen use. That does it for this edition of MedicareMinute. As with all of CGS' educational offerings, this is only a summary of certainpolicy requirements. I encourage you to read the applicable LCD and related Policy Articlefor a complete description of the coverage, coding and documentation requirements. Thank you for watching and have a nice day.

MMMD Affordable Care Act Requirements and Durable Medical Equipment

Hello and welcome to another edition of MedicareMinute MD. I'm Robert Hoover, medical director at CGS Administrators, the JurisdictionC DME MAC. Today I'm going to talk about legislation that impacts your documentationfor Medicare beneficiaries receiving certain items of durable medical equipment or DME.The Affordable Care Act changed many aspects of healthcare, including Medicare. One sectionin particular impacts physicians and other allied health professionals serving Medicarebeneficiaries. Section 6407 of the ACA requires that for certain items of DME, you must providea written order to the DME supplier before they can deliver the item of DME to the beneficiary.In addition, you must conduct an inperson,

facetoface encounter with the beneficiarywithin 6 months prior to writing the order. These requirements went into effect for anynew orders written on or after July 1, 2013. Let's talk about these requirements in moredetail. Section 6407 of the Affordable Care Act establisheda rule requiring a facetoface encounter with the Medicare beneficiary (including theuse of Medicareapproved methods of telehealth) as a condition of payment for certain itemsof DME. In addition, these items of DME must have a written order prior to delivery.The major provisions of this rule include: 1. A physician, physician assistant, nursepractitioner, or al nurse specialist

must document that they have had a facetofaceexamination with a beneficiary in the six (6) months prior to the written order forthe items of DME. 2. This facetoface examination must documentthat the beneficiary was evaluated or treated for a condition that supports the item oritems of DME ordered. 3. There are 155 items covered under the facetofacerequirement and the list is updated annually by CMS. The criteria used to select the 155coved items were:  Items of DME with a price ceiling of atleast $1000 on DMEPOS Fee Schedule; or,  Items of DME that were the subject ofan Office of Inspector General report since

the year 2000; or, Items of DME in the Program Integrity Manual Chapter 5.2.3.1, currently requiringa written order prior to delivery; or,  Items of DME that historically have beenthe target of fraud, waste or abuse. Note that power wheelchairs are not on thislist because they are already subject to a different statutory requirement for a facetofacevisit. In addition, you may recall that the originalACA legislation required that a physician cosign the facetoface documentation forexaminations conducted by physician assistants, nurse practitioners and al nurse specialists.Moreover, physicians were allowed to bill

a specific Gcode for this review and cosignature. The ACA legislation was modified in early2015 by the Medicare Access and CHIP Reauthorization Act. This law removed the requirement forthe physician cosignature on nurse practitioner, physician assistant or al nurse specialistnotes and as a result, also eliminated the ability of the physician to bill the additionalGcode for this work. So let's dig a little deeper into some ofthe facetoface requirements. As I mentioned, the physician, nurse practitioner,physician assistant or al nurse specialist must have a facetoface examination withthe beneficiary in the six (6) months prior

to the date of the written order for the specifieditems of DME. This facetoface requirement includes examinationsconducted via the Centers for Medicare Medicaid Services (CMS)approved use of telehealthexaminations. For prescribing any item of DME on the ACAlist, which we'll talk about in a minute, the exam must:1. Be conducted inperson with the beneficiary within the six (6) months prior to the dateof the prescription. 2. This exam must document that the beneficiarywas evaluated or treated for a condition that supports the need for the item or items ofDME ordered.

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