CPAP accessories: CMS shifts gears on documentation rules

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Friday, August 12, 2016

WASHINGTON – CMS will now assume that medical necessity has been established for replacement of essential accessories for beneficiary-owned CPAP device and RAD.

This does not mean that CMS or its contractors can’t determine that payments for the equipment were inappropriate based on additional information or investigations related to audits, the agency stated in a bulletin last week.

“This assumption is merely made so that initial claims for essential accessories used with a beneficiary-owned CPAP device or RAD purchased by Medicare following 13 months of continuous use cab be processed timely to ensure beneficiary access to these items,” CMS stated.

Under the new assumption, the documentation needed to establish medical necessity for the equipment (e.g. sleep tests) is not needed to establish medical need for replacement accessories alone, according to the bulletin.

All that is necessary for processing claims for replacement of essential accessories used with a beneficiary-owned CPAP device or RAD is a determination that the medical need for the equipment continues, and that the claim for the accessories are reasonable and necessary, CMS says.

This new policy does not apply to replacement of a CPAP device or RAD that has been used for less than 13 months of continuous use or for replacement of accessories for a CPAP device or RAD that is owned by the beneficiary but was not purchased by Medicare. In these cases, all medical necessity documentation needed for the initial use of the CPAP device or RAD must be furnished, according to the bulletin, but the 120-day grace period would apply for transitions to contract suppliers at the start of the Round 2 re-compete.