Home sleep tests: Medical directors await instruction

Sunday, May 11, 2008

WASHINGTON - It could be several months before the industry gets specifics on home sleep testing.

On March 13, CMS issued a national coverage determination (NCD) supporting coverage for at-home sleep tests. Since then, providers have anxiously awaited details from the four DME Medicare Administrative
Contractors (MACs) in the form of local coverage determinations (LCDs).

"The medical directors are working on a revision of the CPAP LCD and policy article," said Dr. Robert Hoover, Jurisdiction C medical director, last week. "We will work collaboratively to ensure that the LCD and policy article is consistent across all four DME MAC jurisdictions."

It may be a while, however, before providers see the fruits of their labor. CMS has yet to issue a change request to the MACs, and with national competitive bidding issues occupying much of the agency's attention, that won't happen any time soon, says Kelly Riley, director of The MED Group's National Respiratory Network.

"We feel their plate is full," she said. "One of the medical directors told me it could be as late as October."

Once CMS issues a change request, the medical directors have 90 days to finalize the policy.

A couple of LCDs released in March and April caused confusion among providers. It is important to remember, Hoover said, that within each MAC, there are several Part B local carriers and Part A fiscal intermediaries who have jurisdiction over payment for the tests, both facility-based and portable. Any time there is a HCPCS code change, LCDs are updated and released, but they continue to reflect the old coverage guidelines for home sleep testing.

"Part A and Part B contractors already have policies outlining the coverage and payment rules for these tests," said Hoover. "They will be responsible for revising their policies to comply with the requirements in the NCD related to home sleep tests."

For providers wondering how to take advantage of at-home sleep testing, key questions remain: What is the reimbursement for the tests? Who can perform them? And what documentation is needed for continued treatment after a required 12-week trial period?

"Everyone wants to make sure this is done well," said Riley. "The intent of the NCD was geared toward primary OSA patients, and I think our industry has a responsibility to implement the practice in the manner it was intended."

Nevertheless, Riley expects things to heat up as physicians, sleep labs and industry associations lobby for the LCDs to include certain requirements.

"CMS established the base rules," she said. "But you've got a set of players positioning themselves to fight anyone else being involved in testing."