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Reimbursement: Understand new flexibility

Reimbursement: Understand new flexibility

Noel NeilQ. Can I apply the same new guidance for PAP masks to other accessories? 

A. In February 2024, the DME MACs published a Dear Physician Letter (DPL) clarifying Medicare’s stance of masks for PAP and RAD devices. The DPL specifically addressed the PAP and RAD device masks, but does the same flexibility apply to other accessories such as tubing, cushions or pillows?  

The letter indicates: 

In order to promote patient adherence to PAP or RAD therapy, the treating practitioner may list the mask(s) in the “General Description of the Item” on the SWO as (not all-inclusive):  

  • CPAP Mask  
  • Mask of Choice  
  • Mask – Fit to Comfort  
  • Mask – one per three months  

Use of these general descriptions on the SWO, as opposed to a specific mask type (i.e., full face mask), will eliminate the need for a new SWO each time a patient switches their mask type. In situations where the mask type is specified on the SWO and the patient needs to change mask type, a new SWO would be required.  

Alternatively, the treating practitioner may indicate multiple mask types on the SWO, so that DMEPOS suppliers are able to provide the mask that works best for the patient.  

While the DPL stops short of clarifying if the same applies to other accessories such as tubing, pillow, cushion etc., I believe the same cadence applies. Requiring a new prescription with each interface change would have the same impact as the old mask guidance did. 

Suppliers are reminded that the treating practitioners must still document in the patient’s medical record the need for PAP or RAD therapy; however, it is not necessary to document in the patient’s medical record the rationale for a specific mask/interface. 

Important to note: The DPL points out “while this flexibility allows for changes in mask types each month, treating practitioners are reminded that Medicare covers only one mask every three months, regardless of the number or type of mask prescribed for an individual patient.” 

Noel Neil JM, CDME, is vice president of corporate compliance and auditing for ACU-Serve. Reach him at 561.778.4454 or [email protected].


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