Obstructive Sleep Apnea (OSA) Documentation Checklist
To increase efficiency in claim submissions and remittances, we have created a Triton OSA Documentation Checklist. Included are some additional details to help you review, scan and upload the appropriate documentation with ALL required information. Best practice is all documentation be uploaded PRIOR to claim submission. These forms are located on our website, click the button below to view:
The Rx or Detailed Written Order include the following:
- Prescribed by an MD, NP, PA, DO or clinical nurse specialist
- Prescriber’s name, NPI, patient name, order date, diagnosis code (G47.33), E0486 Custom Fabricated Appliance for OSA, physician signature, signature date
- Medicare patients require Rx or DWO within 6 months of the face to face exam
MUST BE SPECIFIC AND INDICATE E0486 with a description of the code.
The PSG or HST with interpretation by a Board-Certified Sleep SpecialistMedicare/Medicare Replacement Note: Sleep Study must be within 12 months of delivery date of E0486.
AHI or RDI is greater than or equal to 15 events per hour with a minimum of 30 events OR
The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of the following:
a. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia.
b. Hypertension, ischemic heart disease, or history of stroke; or,
If the AHI> 30 or the RDI> 30 and meets either of the following:
a. The beneficiary is not able to tolerate a positive airway pressure (PAP) device; or,
b. The treating physician determines that the use of a PAP device is contraindicated.Commercial policies: Sleep study should be within 2-3 years (disclaimer – policy by policy varies and subject to change)
Epworth, CPAP Intolerance Form and Dental Questionnaire
It is recommended the provider or auxiliary staff review this verbally with the patient. A score of 11 or more is indicated to show excessive daytime sleepiness
.Make sure the Epworth, CPAP Intolerance Form and Dental Questionnaire are all signed and dated.
Face to Face Notes PRIOR to the sleep study
Medicare, Medicare Replacement Plans, UHC and other carriers that follow Medicare guidelines request Face to Face notes from the referring physician PRIOR to the sleep study to assess the beneficiary for Obstructive Sleep Apnea. PLEASE READ THESE NOTES PRIOR TO UPLOADING as the physician may not know exactly what needs to be included. The clinical note should cover the following:
- Medical History
- Signs and symptoms of sleep disordered breathing including snoring, daytime sleepiness, observed apneas, choking or gasping during sleep, morning headaches
- Duration of symptoms
- Validated sleep hygiene inventory such as the Epworth Sleepiness Scale
- Physical Examination
- Body Mass Index (BMI)
- Neck circumference
- Focused cardiopulmonary and upper airway evaluation
If the carrier is Tricare, HMO, or IPA plan, it is important to obtain a referral from the assigned primary care physician to see the patient for treatment.
DENTIST: Upload all clinical documentation from the dental provider in a S.O.A.P. note format including Intake forms.
The Proof of Delivery should contain the following and should be obtained at the Appliance Delivery appointment (date on POD must match date of service for item billed):
- Description: FDA approved appliance to control sleep apnea (E0486)
- Brand name
- Serial #
- Doctor’s name
- Beneficiary’s name
- Beneficiary’s address
- Beneficiary’s city, state, zip
- Signature of Patient or Legal Guardian with DATE
- Signature of Witness with DATE
Medicare, Medicare Replacement plans and other carriers that follow Medicare guidelines require that the appliance is PDAC approved (Medicare Pricing, Data Analysis, and Coding). Use the following link to look up: https://www.dmepdac.com/dmecsapp/ProductClassification/Search. The lab invoice needs to be scanned and uploaded with appliance details.
Medicare Same or Similar
Medicare will not cover the E0486 if the patient has a history of CPAP, bi-PAP, or previous E0486 in the past 5 years due to “Same or Similar”. These all treat G47.33 and a different piece of equipment will not be covered to treat that same diagnosis.
Triton’s Eligibility Specialists will check for “Same or Similar” when doing the benefit check.IF the patient has had a CPAP, bi-PAP or another E0486 in the past 5 years, Medicare will likely NOT cover the additional equipment. It is recommended that the provider obtain an ABN from the patient and advise the patient accordingly.
IF “Same or Similar” applies, you must request face to face clinical notes* from the physician AFTER CPAP/biPAP usage documenting a change in condition that substantiates why the CPAP/biPAP treatment is no longer indicated (CPAP adjustments attempted, report of patient compliance) and recommendation of E0486.
* Face-to-face cannot indicate that CPAP was successful in any way.
An Advance Beneficiary Notice (ABN), also known as a waiver of liability, is a notice a provider should give a patient before they receive a service if, based on Medicare coverage rules, the provider has reason to believe Medicare will not pay for the service.
The provider may give to a patient if they have had a CPAP, bi-PAP, or E0486 (Oral Appliance Therapy) in the past 5 years (“Same or Similar”).
The provider may give to patient if you have any reason to suspect that Medicare MAY NOT PAY.
An ABN must cite the notifier’s reasons for believing Medicare payment will be, or is likely to be, denied. Simply stating “medically unnecessary” or the equivalent is not an acceptable reason. Must be specific, (ie. “Medicare does not pay due to Same or Similar”).
Patient must select Option 1, Option 2 or Option 3 and SIGN and DATE. The provider CANNOT complete the options section for the patient.
The ABN allows the patient to decide whether to get the care in question and to accept financial responsibility for the service (pay for the service out-of-pocket) if Medicare denies payment.
Cannot give these out to every patient unless there is an indication (such as “Same or Similar”).
ABN’s DO expire so be sure to check the bottom of the page of the form. Updated forms are located on our website in the link below.