Establishing Continued Medical Need and Continued Use
by Andrea Stark
The American Sleep Apnea Association estimates that approximately 22 million Americans have sleep apnea, so demand for devices that treat the condition is high. Unfortunately, according to data from the Centers for Medicare & Medicaid Services, more than 50 percent of positive airway pressure (PAP) claims contain errors.
While PAP devices may have one of the highest error rates, they’re by no means the only products with high errors. In fact, any products that require documentation to establish “continued medical need” and “continued use” may be more prone to errors. Here’s what you need to know to help you ask for exactly the documentation you need.
Continued Medical Need:
Ongoing coverage for equipment that remains in use requires documentation establishing that the equipment continues to be medically necessary. These are the types of documentation that support “continued medical need”:
- A recent order for refills of supplies by the treating physician (only applies to items that have associated recurring supplies)
- A recent change in prescription (modifying the original directives)
- A properly completed CMN with an appropriate length of need specified (only applies to the official CMS-approved forms)
- Timely documentation (within the past 12 months for items not subject to the face-to-face requirement and within the past six months for items subject to face-to-face) in the patient’s medical record showing usage and need of the item
“Continued use” is the term used to describe a patient’s ongoing utilization of supplies or rental items. These types of documents support continued use:
- Supplier records that document refills or additional supplies in compliance with refill documentation requirements; may also document continued use for base items if base items require recurring supplies (e.g., CPAP accessories justifying CPAP equipment)
- Supplier records that document the beneficiary’s confirmation of continued use of rental items
- Timely documentation (within the past 12 months) in the beneficiary’s medical record showing usage of the item, related options and accessories, and/or supplies
While managing these details is likely to prove challenging, there are tools that can help, such as automated systems designed specifically for document management and compliance. Whatever system you put in place, be sure that it’s designed to help you take a proactive approach to collecting and retaining documents. That way, you can avoid errors in rental and resupply billing and achieve compliance with every claim.