Continuous Positive Airway Pressure Devices & Accessories

Affected Providers

Treating practitioners and DME suppliers who bill for continuous positive airway pressure (CPAP) devices and accessories.

HCPCS & CPT Codes

Local Coverage Determination (LCD): Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L33718) has the current HCPCS and CPT codes. 

Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for CPAP is 12.5%, with a projected improper payment amount of $146.1 million.

We cover CPAP devices and accessories under the DME benefit. You must meet the provisions in National Coverage Determination (NCD): Continuous Positive Airway Pressure (CPAP) Therapy For Obstructive Sleep Apnea (OSA) (240.4). We outline other policy requirements in LCD L33718.

CPAP therapy is a non-invasive technique for providing single levels of air pressure from a flow generator, through a nose mask and through the nares. The purpose is to prevent collapse of the oropharyngeal walls and obstruction of airflow during sleep that occurs in OSA.

Denial Reasons

Insufficient documentation accounted for 71.2% of improper payments for positive airway pressure devices during the 2024 reporting period, while medical necessity (9%), incorrect coding (0.3%), no documentation (0.2%), and other errors (19.3%) also caused improper payments. Other errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.

Preventing Denials

These Medicare coverage and payment guidelines apply to CPAP device claims:

• The treating practitioner conducts an in-person clinical evaluation of the patient before the sleep test to assess them for OSA
• The patient has an approved sleep test for 1 of these:
  • Polysomnogram (PSG) attended by qualifying practitioner and done in a sleep lab
  • Unattended home sleep test (HST) with a Type II or Type III home sleep monitoring device
  • Unattended HST with a Type IV home sleep monitoring device that measures at least 3 channels
• The sleep test meets either of these requirements:
  • Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) is greater than, or equal to, 15 events per hour with at least 30 events
  • AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour, with at least 10 events and documentation of:
    • Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia
    • Hypertension, ischemic heart disease, or history of stroke
• When providing the CPAP, document that you've instructed the patient or their caregiver on how to properly use and care for the equipment

Continued coverage after 12 weeks depends on practitioner reassessment and documentation of patient therapy regimen adherence and improvement of OSA symptoms.

Refill Requirements

For DMEPOS items and supplies provided on a recurring basis, base your billing on prospective, not retrospective use.

Documentation Requirements

To justify payment, you must meet specific requirements when ordering DMEPOS.

Example of Improper Payments Due to Insufficient Documentation for CPAP Devices

A supplier bills the claim for HCPCS code E0470 (Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)) and submits the following documentation per the review contractor’s request:

• Standard written order with correct HCPCS coding
• Treating practitioner’s medical record that doesn’t include sleep test results
• Proof of delivery

What Documentation Was Missing?

The patient’s medical record doesn’t include the sleep test results and therefore doesn’t meet medical necessity requirements for a CPAP device.

What Happens Next?

The review contractor completes the claim as an insufficient documentation error, and the Medicare Administrative Contractor recoups payment.

Recommendation

To prevent claim denials and improper payments, the certifying physician must collect and submit proper documentation for medical necessity in the treating practitioner’s medical record for DMEPOS, including:

• Satisfaction of sleep test criteria, defined as either:
• AHI or RDI greater than or equal to 15 events per hour, with at least 30 events
• AHI or RDI greater than or equal to 5 and less than or equal to 14 events per hour, with at least 10 events
• Documentation of:
• Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia
• Hypertension, ischemic heart disease, or history of stroke

For specific policy requirements, see LCD L33718.