While obstructive sleep apnea (OSA) therapy and its related profit potential have been a hot topic in the field of home health for the past few years, the most important part of the sleep therapy story may be how it is changing the lives of OSA patients. Take, for example, the experience of the retired railroad employee and sleep apnea patient from Pennsylvania who was so tired before he began receiving nightly continuous positive airway pressure (CPAP) therapy that he was afraid to drive.

“I thought I would fall asleep behind the wheel,” he said when interviewed for this article.

With treatment, such worries are now a thing of the past. “This machine has helped me a lot,” he explained. “I don’t get up in the morning feeling like I never went to sleep anymore.”

This man is one of the lucky ones. Researchers have found that untreated, the frequent interruptions of breathing during sleep that characterize sleep apnea place the patient at risk for a multitude of potentially life-altering and possibly life-threatening consequences such as hypertension, cardiovascular accident or CVA (stroke), cardiac arrhythmia, and myocardial infarction. In addition, the excessive and unrelenting daytime sleepiness experienced by the patient with sleep apnea may frequently lead to irritability, memory loss, decreased decision-making skills, and an overall deterioration in the patient’s emotional and mental health.

Providers Spread the Message
Researchers now estimate that as many as 18 million Americans have sleep apnea. HME suppliers, recognizing the benefits (and profitability) of sleep therapy, have worked diligently to educate their client base about new reimbursement guidelines in addition to the therapeutic benefits to be obtained from the use of sleep apnea therapy.

But challenges remain, including educating referral sources, getting patients the proper qualifying tests, ensuring patient compliance with treatment, and getting insurers to pay for treatment.

To begin with, before a patient can be treated, a definitive diagnosis of sleep apnea should be confirmed by a physician with specialty training in sleep disorders. Often, the patient is required to undergo a polysomnography or a multiple sleep latency test (MSLT).

The polysomnography study records a variety of body functions while the patient is asleep. Electrical activity of the brain, heart rate and respiratory effort, muscle activity and eye movement, airflow, and blood oxygen levels are all routinely monitored during the sleep study to diagnose sleep apnea and its severity. The length of the polysomnography study varies by individual and may be performed as either a whole-night study for diagnosis purposes only or as a split-night study. In the split-night study, the patient is diagnosed and initial treatment with a positive airway pressure device may be started and evaluated.

Proper Testing is Key
Under Medicare medical policy guidelines, the qualifying study must record a minimum of 2 hours of actual sleep without the application or use of a positive airway pressure device. The study must include sleep staging (studying brain electrical activity) and the patient’s parameters for airflow, respiratory effort, and oxygen saturation.

The MSLT is performed to measure the speed with which a patient falls asleep. The patient is given several opportunities to fall asleep during the period of the day when they would normally be awake. Patients who fall asleep in less than 5 minutes are usually identified as having a sleep disorder. The MSLT is also used to measure the degree of daytime sleepiness and to rule out other types of sleep disorders.

Diagnostic testing for sleep disorders is usually conducted in a sleep disorders center. The development of new technology now allows some sleep studies to be performed in the home, but these studies are not currently accepted by Medicare or many of the major insurance carriers. Suppliers must be careful to verify the location of the study performed when qualifying patients. Medicare guidelines require that the polysomnographic study be performed in a facility-based sleep study laboratory and that the laboratory is a qualified Medicare provider. Test results from a study performed in the home or in a mobile facility are not accepted. The supplier should verify the test location guidelines mandated by other insurance carriers before accepting the patient into their service. A listing of accredited sleep centers may be accessed on the American Academy of Sleep Medicine Web site at www.aasmnet.org/listing.htm.

Once a definitive diagnosis of sleep apnea is established, the physician specializing in sleep disorder therapy will determine the most effective treatment protocol for the patient. The individual treatment protocol prescribed takes into account the patient’s medical history, most recent physical examination findings, and sleep study results. Although oxygen may be prescribed to a patient with central apnea caused by heart failure, it is not an effective method of treatment for the patient who has been diagnosed with sleep apnea. Accepted treatment methodologies for sleep apnea include dental appliances, surgical procedures, behavioral therapy, and, the most common method of treatment, CPAP.

Medicare Loosens Coverage Criteria
Recognizing the overall effectiveness of CPAP therapy and its role in reducing serious side effects, the Centers for Medicare and Medicaid Services (CMS) issued revised guidelines for the coverage of CPAP devices to the Local Medicare Review Policy (LMRP). Effective for dates of service after April 1, 2002, the guidelines reduced the length of time required for the polysomnographic study to 2 hours and reduced the total number of apnea episodes previously required for reimbursement under Medicare. In addition, Medicare allowed episodes of hypopnea to be combined with apnea episodes to create a total apnea hypopnea index (AHI), accepted for qualifying the patient under medical necessity guidelines. Plus, physicians are no longer required to complete the tedious certificate of medical necessity to qualify a patient for a CPAP device. Instead they can prescribe the device with just the completion of a physician order.

There was one new caveat in the revised guidelines; after the 60th day of CPAP therapy, the supplier is required to obtain a statement from the beneficiary or physician noting continued use of the CPAP device. This makes ensuring patient compliance through proper mask fit and education all the more important for the supplier. Thanks to a combined effort by manufacturers and providers to educate patients and referral sources, the increase in sleep therapy use is now benefiting many more patients.

Helen M. Farrell is a reimbursement consultant and CEO of MARS (Medical Accounting & Reimbursement Services) in Chesapeake, Va. Contact her at (757) 410-1732.