Are PAP-Naps a billable service?

We currently do PSGs, CPAP titrations, and monthly compliance therapy meetings. We are looking to increase our services by doing HST and PAP-Naps. My question is about PAP-Naps and if it is a billable service. I have been told as long as we code the procedure with the modifier 52 code it should be covered. I have also been told that it should be included in the titration so it isn't a billable procedure. I think for some patients having a hard time tolerating their mask/pressure that the PAP-Nap is a good service, but if it isn't a billable procedure I don't know if we can staff for that. 

The PAP-NAP, a procedure for daytime desensitization, was devised by our sleep medical team with the assistance of our Regional Medicare Medical Director. The expediency of the procedure is that it not only works extremely well for patients struggling to adapt to the mask or pressurized airflow or both, but also, we discovered that an existing CPT code (95807) could be used for billing and reimbursement. The PAP-NAP was implemented because we recognized the urgent need for patients to work directly with sleep technologists during the day time, one-on-one, and for longer intervals of time. Most PAP-NAPs range from 2 to 5 hours with an average length of 3.5 hours at our center.

In discussing the premise of the PAP-NAP with numerous national and regional Medicare officials in 2004, we were pleasantly surprised how receptive they were to the idea that sleep technologists working during the daytime with problematic patients could improve compliance. We were especially fortunate that our regional medical director embraced the model and explicitly recommended we use the existing code and not expend time applying for a new code. And, we were fortunate at that time to refer to a citation from the old ASDA (now AASM), which actually detailed the use of CPT 95807 for the facilitation of CPAP use.(1)

So, CPT 95807 fit well and was already established, but after many thoughtful discussions about the expected time element involved for PAP-NAPs, we wanted to prevent any sense of confusion or "overcharge" that might concern Medicare officials, so there was concurrence on the addition of the 52 modifier to indicate an "abbreviated" study, which we include in the title of the reports we generate for the PAP-NAP. We even discussed the fact that the term "abbreviated" usually meant a study was foreshortened as in a diagnostic study less than 5 hours (leading to coding of 95810-52), but Medicare still felt the modifier was appropriate. Looking back since the implementation of the PAP-NAP, it has occurred to me that the one-on-one tech to patient encounter may compensate for the shorter time element and obviate the need for the 52 modifier. We still use 95807-52 and have done so since 2004 with virtually all studies reimbursed, including Medicare studies. Of interest, we are aware of some centers using either the stand-alone 95807 or the 95807-52, and all these centers are reporting successful reimbursement.

It is concerning to hear about billing problems for a PAP-NAP. What we have learned in some instances is that centers or labs may submit their bills but never apparently follow-up with those insurance entities that reject the claim. Although it is clearly frustrating and time-consuming to make these explanatory phone calls to insurance carrier medical directors, most of the conversations turn out informative and worthwhile. Most medical directors welcome this type of input, and most are quite sensible and realize the rationale and utility for the PAP-NAP for problematic cases.

There are always exceptions to the rule, and here are three examples to consider from real-world sleep medicine in just the past year. A few of our carriers wrote policies to not cover PAP-NAPs. I phoned all these carriers to conduct lengthy or multiple conversations with their medical directors, and in one local situation, I presented a 30-minute PowerPoint lecture with Q & A to a group of medical directors and staff. In each of these three instances, the verdict went against us in so far as these entities stated they would not change the policy as yet. Nonetheless, within a matter of weeks (and ever since for all three carriers), we requested and received approvals (sometimes with a bit of delay) to conduct PAP-NAPs on highly problematic patients. For some of these carriers we must now use a prior authorization step, but the procedure is rarely rejected.

We have several PAP-NAP resources available online at our website www.sleeptreatment.com, including an online video and a downloadable PAP-NAP reference guide that provides many details about the procedure as well as demonstrating sample cases and reports that you can edit or modify to suit your practice (the guide comes in both PDF and Word docs). I am very pleased to mention that Classic Sleepcare has been most supportive in our efforts to spread the word about the PAP-NAP, and they regularly inform their clients and associates about the value of this procedure. We also conduct PAP-NAP workshops for training. Here’s a direct link to these resources: www.sleeptreatment.com/index.php?option=com_content&view=article&id=3155&Itemid=2153

With that background, which I trust will prove useful to your efforts, the implied combination of home testing (HST) and the PAP-NAP is an intriguing one on several fronts. First and foremost, it is worth stating that the PAP-NAP could easily be used in a variety of clinical situations. And, when we initially developed this procedure, we thought we would be using it primarily in elderly cardiac patients who were often terrified of PAP therapy. In those cases, we conducted the PAP-NAP before they completed either a diagnostic or a titration PSG, because we recognized many would show severe OSA and oxygen desats to trigger a need for a split night study. We wanted the patient desensitized to PAP before the split-night to address this issue prophylactically and thereby prevent a traumatizing experience in the middle of the night that might forever cause the patient to dismiss even the remote possibility of PAP use.

Having worked with PTSD patients and other trauma survivors for more than 25 years, I do not use the word “traumatizing” with any sense of exaggeration. Many sleep-disordered breathing patients are routinely traumatized by abrupt or otherwise poorly delivered desensitization procedures at sleep centers or labs that have not developed a high quality program to manage those patients who present with the high anxiety or fear about the PAP experience. When improper, ineffective, or poorly delivered desensitization procedures produce a “traumatizing” response, the individual is now conditioned to fear the mask or pressurized air sensations or both, and in many instances, these individuals require several months or a few years before they reconsider the possibility of PAP therapy.

This problem or variations of it are rife within the field of sleep medicine, and regrettably many sleep professionals in our field do not recognize how this process unfolds in many patients. It is particularly common among patients with complex insomnia(2), the term we devised in 2001 to describe insomnia patients with covert OSA or UARS (the type of patient that most frequently undergoes a PAP-NAP at our center). That said, the PAP-NAP creates a wonderful opportunity to nip this common problem in the bud by not pushing PAP therapy onto a patient who is not quite ready to experience it. Therefore, at minimum, if after a patient completed an HST and a problem with anxiety were identified, the PAP-NAP would be an excellent next step, because this PAP “test-drive” truly relieves a great deal of anticipatory anxiety and imaginative catastrophizing that erupts in patients who know little to nothing about the PAP device.

While the above model appears to make the most sense regarding the use of the PAP-NAP, the question we should all be asking ourselves is whether or not there will be cases in which a new sequence could be developed that involves three steps: 1) HST diagnostic; 2) PAP-NAP; and 3) prescription to initiate PAP therapy. This proposed sequence sparks some interesting clinical and research questions, chief of which is the true validity of the practice model that declares a first titration in most patients will determine optimal pressure settings, and therefore repeat titrations are unnecessary. As we have described elsewhere (3), we believe this model may work well for typical or classic sleep apnea patients who suffer severe daytime sleepiness, no anxiety, and no complicating medical or psychiatric co-morbidities. It is our perception that this cohort accounts for a very small proportion of patients who present to sleep medical centers or lab. Thus, we reject this “typical” model as viable for the large majority of patients presenting for treatment of sleep disorders.

If our perceptions are accurate regarding the lack of definitive pressures on a first titration, then it would seem quite reasonable to prescribe PAP devices to some patients directly after a successful PAP-NAP to “strike while the iron is hot.” That same patient would spend time at home adjusting to the device and then return 2 to 4 weeks later for their first full night titration, which might proceed more efficaciously, because the patient’s comfort level would likely to be much higher for having used the device at home for awhile.

We believe this streamlined model will prove very reliable, because after a PAP-NAP you can often discern a patient’s capacity and motivation to use the PAP device. In most instances, the patient not only will prove capable of using the device at home, but also in many circumstances the patient will be relieved about delaying the return to the sleep lab to deal “with all the wires.” Then, when the patient does return in 2 to 4 weeks, the wires feel less intrusive because the patient suffers less overall anxiety about what’s expected of them during the titration.

Common sense suggests the PAP-NAP could ease a lot of patient burdens, and clearly it has the potential to improve adherence to the PAP device. In that regard, it’s likely to prove a real cost-saver in many realms of sleep medicine. Hopefully, greater support from insurance carriers for this model of care will be forthcoming, especially as these institutions start recognizing that greater PAP adherence leads to reduced healthcare costs.

REFERENCES

1 Indications for Polysomnography Task Force, American Sleep Disorders Association Standards of Practice Committee. Practice parameters for the indications for polysomnography and related procedures. Sleep 1997;20:406-22.

2 Krakow B, Melendrez D, Pedersen B, et al. Complex insomnia: insomnia and sleep-disordered breathing in a consecutive series of crime victims with nightmares and PTSD Biological Psychiatry, 2001,49(11):948-953.

3 Krakow, B. Paving the Way to Optimal Titrations: The PAP-NAP Sleep Review, October 2011 at www.sleepreviewmag.com/2011/10/paving-the-way-to-optimal-titrations


Barry Krakow MD

Author

Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.



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