With an estimated 53% of the HME industry’s revenue in the year 2000 coming from respiratory products and the increasing ratio of Medicare beneficiaries over the next 10 years, respiratory issues have been and always will be a focal point of discussion at the Medicare reimbursement roundtable.

Given the amount of money involved, increased scrutiny of Medicare respiratory reimbursement is to be expected.

Unfortunately, when the government looks at what it pays for respiratory products, it rarely takes into consideration the services HME providers furnish to respiratory home health care patients. Medicare respiratory product reimbursement is often compared to the Department of Veterans Affairs reimbursement structure where delivery, setup, interactive instructions, and other services are not provided. HME providers receive neither credit nor reimbursement for the extra services—such as access to experienced respiratory therapists on staff—commonly supplied to Medicare respiratory patients.

Instead, news stories focus on the fraudulent providers that intentionally disregard the antikickback statute or receive monies from Medicare, Medicaid, or third-party payors for services they did not provide. They almost never report that there are more legitimate providers than fraudulent ones.

If you are one of the many legitimate HME providers who rely on Medicare respiratory reimbursements as the “bread and butter” of your business, you need to fight for your business and for home health care respiratory patients.

Currently, two important respiratory billing issues are oxygen recertification testing rules and the changes in the the continuous positive airway pressure (CPAP) device reimbursement policy.

O2 Recertification Headaches
The largest category of Medicare respiratory reimbursements is home oxygen therapy. Medicare coverage guidelines for oxygen are fairly straightforward with the exception of a few key items. Oxygen is the only respiratory product that requires an Office of Management and Budget (OMB) approved Certificate of Medical Necessity (CMN). Oxygen requires the 484.2 CMN along with additional medical documentation such as laboratory results, physician progress notes, discharge notes, and anything else you may obtain to prove medical necessity.

However, many Benefit Integrity Unit (BIU) investigations have found that oxygen providers were overpaid for patients who require a 1-year recertification CMN for oxygen. When a patient needs to be recertified to continue to qualify for home oxygen therapy, the provider must make sure two processes take place prior to the 1-year recertification CMN.

First, the provider must find out if the treating physician has seen the patient within 90 days prior to the actual recertification date—and the patient’s file must note that this physician visit took place. If the physician did not see the patient within 90 days prior to the actual recertification date, the provider cannot continue to bill until the patient has visited the physician as required by policy.

Second, question No. 1 on the CMN asks for the “most recent test result taken on or before the certification date in Section A.” This means that prior to the 1-year recertification CMN, the provider must also ask the physician’s office, hospital laboratory, and the patient if the patient has been tested since he or she was initially set up on oxygen. Current policy does not require the patient to be retested after they qualify for home oxygen therapy unless the physician chose 12 months as the length of need on the CMN. Therefore, if a BIU investigator finds a qualifying laboratory result showing where the patient did not qualify for oxygen at that time, you will have received an overpayment based on the results found.

Sometimes the physician’s office, hospital laboratory, and/or patient cannot or refuses to say if testing took place after the patient was initially set up on oxygen. If you then provide home oxygen therapy in good faith that you will be reimbursed, you could lose what you were paid if investigators uncover a test that disqualifies the patient for home oxygen therapy.

CPAP Policy Changes
CPAP device sales have increased in volume as physicians are better able to diagnosis obstructive sleep apnea (OSA) cases. In addition, a new national policy that became effective April 1 has increased beneficiaries’ chances of qualifying for CPAP therapy.

According to a Centers for Medicare & Medicaid Services (CMS) May 17 program Memorandum (Transmittal 151, section 60-17), “CPAP devices are covered under Medicare when ordered and prescribed by the licensed treating physician to be used in adult patients with OSA if ... the Apnea Hypopnea Index (AHI) equals 15 events per hour.” In addition, CPAP therapy is covered in certain cases where the AHI is less than 15 events per hour, if the patient has “documented symptoms of daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic [localized red blood cell deficiency] heart disease, or a history of stroke.”

The policy also eliminates the need to furnish CMNs when billing for CPAPs. This means that, as of this past July 1, you should have started to attach the KX modifier (formerly ZX) when billing CPAPs to state that you had everything in the patient’s file required by policy prior to attaching the modifier for payment.

The ZX modifier was a highly audited modifier and the KX modifier may turn out to be equally problematic. Therefore, providers must understand and be aware of the new policy. It is similar to the RAD (Respiratory Assist Device) policy in having documentation requirements after 3 months of use before you can continue billing with the appropriate modifier. Test your employees on the new policy and verify they truly understand what is required.

To download a copy of the policy in Adobe Acrobat portable document format (pdf), visit www.hcfa.gov/pubforms/transmit /r151cim.pdf. Or contact your local Durable Medical Equipment Regional Carrier (DMERC) for a copy.

With the daily changes occurring in the respiratory industry, it is vital you keep up with those changes and become active in industry issues. Take a deep breathe, go see a patient, and know that respiratory issues are here to stay but you can deal with them.

Jane W. Bunch, RT, is CEO of JB&CS Inc, Marietta, Ga, and president of B&B Online HME Services Inc, also in Marietta. Contact JB&CS at (678) 445-1221.