Positive Airway Pressure Therapy Order Checklist

When ordering a PAP machine, please provide the required documentation listed below:
  • Patient Demographic Information
  • Standard Written Order
  • Qualifying Polysomnography (PSG) Sleep Study
  • Chart notes documentation of a face-to-face evaluation with the patient stating the reason for prescribing PAP therapy.     
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Standard Written Order (SWO)

A PAP therapy SWO must include the following elements to be valid:

  • Patient Name
  • Order Date
  • General description of the item
    • The description can be a general description, an HCPCS code, an HCPCS code narrative, or a brand name/model number
    • For equipment: In addition to the description of the base item, the SWO may include all concurrently ordered options, accessories, or additional features that are separately billed or require an upgrade code (list each separately)
    • For supplies: In addition to the description of the base items, the DMEPOS order/prescription may include all concurrently ordered supplies that are separately billed (list each separately)
  • Quantity to be dispensed
  • Ordering physicians name or National Provider Identifier (NPI)
  • Ordering practitioner

Medicare Sleep Study Requirements

A sleep test was performed and meets all of the following qualifications:
  • The beneficiary’s treating practitioner ordered the sleep test.
  • The test was conducted by an entity that qualifies as a Medicare provider of sleep tests and is in compliance with all applicable state regulatory requirements.
  • The sleep test results meet either of the following criteria:
    • The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (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: Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or, Hypertension, ischemic heart disease, or history of stroke.

Documentation Requirements

Please include chart notes with the following information:
  • Initial clinical evaluation of patient and documentation prior to the sleep test to access the beneficiary for OSA and need for PSG
  • Diagnosis of OSA
  • Planned course of treatment
  • Other therapeutic interventions
  • Results of qualifying PSG or report
  • The practitioner’s signature on the medical records meets CMS signature requirements
After three months of therapy:
  • Follow-up evaluation with prescribing physicians
  • Diagnosis of OSA
  • Compliant use of PAP
  • Benefiting from therapy
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