Articles
SLEEP 2008 Talks Home Sleep Testing
SLEEP 2008 Talks Home Sleep Testing
BALTIMORE — At SLEEP 2008, the American Academy of Sleep Medicine 22nd annual meeting, last week, home sleep testing was a hot topic.
AASM representatives discussed the national coverage determination (NCD) for home sleep testing and reviewed the AASM clinical guidelines for portable monitoring. Alex Chediak, immediate past chair of the AASM, outlined what the Centers for Medicare & Medicaid Services (CMS) did not address in the NCD, including requirements for suitable clinical evaluation, what three channels must be recorded on the Type IV device, the method of titration, the definition of benefit from CPAP, the paradigm for acute and long-term follow-up, and the management of CPAP trial failures.
Chediak also outlined what CMS has done since the NCD in March, which includes the release of HCPCS temporary codes (G0398-G04000) for portable tests. Also, a couple of weeks prior, edits were proposed to the National Correct Coding Initiative (NCCI) to bundle the three G codes with the three CPT codes and other codes for PSG/sleep. Doing so would prevent providers from billing multiple codes at the same time. The revision is expected in October.
Perhaps the most useful information came from Jerry Barrett, AASM executive director. In his presentation, Barrett outlined the policies currently available from the 11 carriers, though he emphasized that this information was only accurate for the next 90 days. According to his research, only half of the carriers have LCD policies on sleep testing and many are not updated yet. He anticipates a 45-day comment period after each LCD is released. Barrett says that when the LCDs are released, providers should be aware of which services are covered and reimbursed; how to properly code services provided, including physician requirements; utilization guidelines; and the ICD-9 codes to support medical necessity. At press time, the carriers had issued LCDs as follows:
• Cahaba Government Benefits Administration — no LCD, but working on one
• CIGNA — no LCD
• First Coast Service Options — no LCD
• National Government Services — has current LCD, which is the same as the current NCD. The carrier is waiting on G codes and information on Type IV tests before the LCD is updated further.
• Highmark — has an LCD
• National Heritage Insurance Co. — The DMAC is writing the policy for the eight states that fall under this carrier. Barrett advised the room to not just look at Part B for the policies, but to look at Part A, Part B and DMAC because all may have an impact on home testing.
• Noridian — will be updated to reflect the NCD, though will probably have some restrictions
• Palmetto — soon to be revised to reflect NCD
• Pinnacle — has a draft LCD, which requires board-certified sleep physicians and/or AASM-accredited facilities to administer portable testing
• Trailblazer — draft LCD released June 4, does not cover portable monitoring. Barrett says he is sure this LCD will be challenged because it does not follow the requirements of the NCD.
• Wisconsin Physicians Services — no LCD, but recently said they may work on an LCD.
Barrett says there is a mechanism to request an LCD policy through petition. Look for G code values to come out in the near future.
Dr. Larry Epstein also presented some concerns regarding independent sleep labs and home sleep testing. He said that HME companies would likely be potential competitors, but it depends on LCD requirements. Other likely competitors in this market include non-local sleep groups, non-sleep specialty groups (i.e. cardiologists), primary care groups and home testing companies. Right now, Epstein says providers should be thinking about how the patient will get the device and how they will return it. Possible options include patient pickup, home delivery and mail. Sleep labs may also rely on HME companies, which already have the infrastructure to make home visits. Epstein warned that some devices would be delayed in coming back or may not be returned at all and that businesses should take that into account when purchasing devices. He recommended that providers make sure they have enough devices in stock to account for multiple tests in one day.
Other considerations for portable monitoring, according to Epstein, include determining who educates the patient about HST devices, which educational materials are needed and implementing staff changes, including on-call tech support.
In a separate meeting, the Sleep Manufacturers Alliance discussed issues pertaining to home sleep testing, including auto-titration, LCDs and G codes, and Type III vs. Type IV devices.
Phil Porte, executive director of the alliance, said pulmonary societies are likely to respond collectively to the LCDs. He also said that contractors must respond to the new NCD on home sleep testing. "Contractors do not that have the unilateral authority to say 'Well, even though national Medicare says it's covered, we decided that it's not.' They just don't have that authority," Porte says. "What we anticipate being a problem is the decision by Medicare to permit local contractors, the MACs or the carriers, to assign payment amounts for the G codes. That is worrisome. We'll see how it plays out."
In terms of Type III and Type IV devices, Porte says there is no objective governmental agency to determine the difference between these devices. "It raises an interesting legal question for a physician, even if there isn't a payment involved," he says. "He or she submits a bill to Medicare or indicates that a home sleep test was done on a Type III device and it was in fact done on a Type IV. But because there's no disinterested governmental agency making that determination, is there some exposure? Has the physician committed fraud? Interesting question. And we're looking at that because the manufacturers want to compete in a fair, level marketplace."
