CMS does about-face on re-supply items

Friday, June 15, 2012

BALTIMORE – CMS plans to change the requirements for certain respiratory supply re-orders and that will have a direct impact on how providers do business, say industry stakeholders.

The biggest change: Providers can no longer replace an item unless the beneficiary's current item doesn't work.

"Now, it's not, 'You are eligible for a new mask,' it's, 'You are eligible for a new mask but is your current mask leaking?'" said Jason Holzman, general manager for

In a notice published June 8, CMS states that for items that need periodic replacement, like PAP and respiratory assist device supplies, providers must determine whether the items remain functional and they can only provide replacements when the supplies are no longer functional.

The change contrasts with CMS's local coverage determination (LCD) for PAP, which allows supplies like cushions, headgear, tubing and filters to be replaced every three months. 

"CMS has clearly established quantity replacement guidelines for all these products," said one stakeholder. "Now it would seem they are implying those guidelines are not valid."

Also problematic: The change, as currently described, is really vague.

"What's dysfunctional?" says Scott Lloyd, president of Extrakare in Norcross, Ga. "With CPAP tubing, does there have to be a hole in it or can the patient just suspect an accumulation of bacteria?"

Additionally, stakeholders worry if providers have to wait if an item is no longer functioning to replace it, that will affect compliance, which affects not only the patient’s health but also their reimbursement.

"Patient outcomes need to be more closely considered in this case," said one stakeholder. "Many times over the years, patients will present to the HME provider with complaints of, 'My therapy doesn't seem to work anymore.' Upon questioning, it is learned the appliance is old, poorly fitting now, and just plain worn out."

While the change seemed to come out of nowhere, it's likely in response to the overall increase of auto-shipment of supplies, like glucose test strips, say stakeholders.

"I think Medicare's goal is to eliminate auto replacement of supplies when they're not needed," said Sylvia Toscano, owner of Professional Medical Administrators. "But, I think the practicality portion of this wasn't considered."



This is beyond ridiculous. First of all, the comment made regarding resupplies for Medicare patients, being sent automatically, this cannot be done with Medicare patients. IF your company is doing this, stop doing it. But what about cleaning?  And not to mention the compliance of the tubing?  This will be the fate of the patient who is readmitted for reoccuring respiratory infections, just in time for Medicare to tell the hospitals that they cannot bill if the patient came in with the same diagnosis 30 days before. 

What an ingenious cycle of denial.

I am sorry, where does it say in the story that anyone is sending these supplies automatically. I'd like to clarify that if necessary, because you are correct. It can't be done automatically and I don't mean to imply that anyone is.



It mentions it, in the second, to last, paragraph.


While the change seemed to come out of nowhere, it's likely in response to the overall increase of auto-shipment of supplies, like glucose test strips, say stakeholders." 

Has anyone figured out a strategy to deal with this yet? I'd love to hear what you're doing..

If you ask me this isn't such a bad idea.  Just a bit more paperwork, per usual.

This will hopefully save some money in the long run for Medicare, but as I said it is easily solved.  Simply make a questionnaire (the first thing I did this mornign when I saw this story) and have your patients complete the questions when they need supplies.  These are questions we typically ask our patients anyhow, so now I have simply made a form to document such.  Until further information is released or a specified form is required, this is what I will be using in my office.

Feel free to use my format I have pasted below. :)



Medicare PAP Re-Supply Questionnaire


June 8 2012, Medicare passed a new guideline stating that when a patient is in need of a PAP re-supply (i.e. mask, headgear, tubing, filter or water reservoir) it must be documented that their current equipment is no longer functional and is in need of being replaced. 

Please take the time to complete the following questions regarding your equipment so that we may document the necessity for replacement of your supplies in your chart. 

Thank you for your time and cooperation in this matter.


1)      How long have you had your current supplies?                                             __________

2)      If you are replacing your mask; are you experiencing a mask “leak”?         Yes       No

3)      If you are replacing your headgear; is your current headgear worn and stretched out, therefore not fitting properly and causing issues with your mask fit?                                Yes       No

4)      If you are replacing your filter or tubing; are you worried there may be bacteria or other build up which may cause you to become ill from extended usage?                                     Yes       No

5)      If you are replacing your tubing; are you worried there may be a pinhole or other malfunction of the product which may cause you to not receive the proper therapy with continued usage, or is there an apparent hole or breakage within the current product?                               Yes       No

6)      Do you feel your health and PAP therapy would greatly benefit from a re-supply of your current PAP supplies today?                                                                                               Yes       No



_______________________________________                                          __________________

Patient Name                                                                                                 Patient ID


_______________________________________                                          __________________

Patient/Caregiver Signature                                                                                    Date

If I had asked my 90 year old father if his CPAP tubing, mask and humidifier chamber were defective, he would have told me no, it was working fine. In fact, he had used the same mask and tubing for 7 - 8 months, thinking it was working just fine. Only after he spent 3 weeks in the VA hospital with a lung infection caused by bacteria from his old supplies did he understand that the items need to be changed on a regular basis to prevent bacteria buildup.

Our older beneficiaries come from an era when the thinking was "if it ain't broke, don't fix it". Unfortunately, the items in questions can be "broke" without being defective.