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CPAP/BIPAP Documentation Checklist


CPAP/BIPAP Documentation Checklist 

  • Patient demographics
  • Face to face chart notes -----prior to PSG
  • PSG or Split Study (also titrated study if ordering BIPAP)
  • Rx with description of items ordered
  • **IF AHI is less than 15 the patient must also have one of the following diagnosis indicated in their progress notes to qualify: excessive daytime sleepiness, hypertension, impaired cognition, mood Medicare only considers long term oxygen therapy for payment; short term therapy for an acute condition is not a covered benefit.
  • disorders, insomnia, ischemic heart disease, history of stroke
  • If home test includes sleep test instructions and test

For ordering BIPAP ALL the above applies and the following is also required:

  • A Cpap has been tried and proven ineffective based on a therapeutic trial conducted in either facility or in a home setting
  • Ineffective is defined as documented failure to meet therapeutic goals using a Cpap during the titration portion of a facility-based study or during home use (i.e. proper mask fitting and selection with appropriate pressure settings)
  • A NEW Face to Face is required for Bipap if the patient has used a Cpap for more than 3 months
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