Correct Medical Billing For Sleep Apnea

Correct Medical Billing For Sleep Apnea

With the increasing number of patients with obstructive sleep apnea, the DMERC recently changed it’s requirements for the medical billing of a CPAP machine. A CPAP machine is a continuous positive airway pressure device. It is used to assist patient in breathing at night. Recently, the DMERC has made the restrictions less harsh when it comes to doing medical billing for these devices.

In 2002 new requirements were set for the purchase of CPAP machines. A patient now has to meet one of the two criteria. The first criteria for medical billing is that the patient’s AHI is greater than or equal to 15 events in an hour. The second criteria that can be met is if the AHI is between five and fourteen events per hour, then there has to be other documented symptoms. These symptoms include: hypertension, daytime sleepiness, mood disorder, impaired cognition, or history of stroke.

Due to these new medical billing CPAP changes, documentation is a must! Now, if the patient has an AHI between five and fourteen events, there must be thorough documentation to back up the other necessary symptoms. When the claims are filed, correct medical billing protocol in this case is to use modifier KX. This modifier means that the DMERC medical billing criteria has all been met.

It is very important not to depend on the physician to record all the necessary elements. Many times it is not the physician doing the medical billing for the CPAP machine. That means, they do not lose money if the proper protocol is not followed. To make sure all elements are met, be sure to get a copy of the polysomnogram. Letters of medical necessity are no longer needed because they only ask questions that pertain to the old medical billing policy.

Performing medical billing for sleep apnea is now much more rewarding. The alterations to the CPAP criteria are a positive medical billing change.

View all Articles by: Melissa Clark, CCS-P