Sleep-apnea claims sit at the intersection of three specialties: pulmonology, DME, and sleep medicine. Each brings its own documentation rules, and payers enforce them all.
Missing AHI threshold documentation
Most payers require an AHI ≥ 5 with symptoms, or ≥ 15 without, to cover a CPAP. The sleep-study report must clearly state the AHI — not just attach it as raw data.
Prior authorization gaps
CPAP, BiPAP, and oral-appliance therapy almost always require prior auth. A single missing auth ID will bounce an otherwise clean claim.
Compliance requirements for rental continuation
Medicare’s 90-day compliance rule — four hours of use on 70% of nights in any 30-day window — applies to most commercial payers too. Document compliance downloads monthly.
Incorrect HCPCS for the device
E0601 is not the same as E0470, and modifier KX versus GA matters. A DME-aware scrubber catches the mismatches before they cost you.
Failure to bill for interpretation separately
The sleep-study interpretation (95810 professional) and the home-sleep-test read (95806/G0399) are often billable on top of the study itself, if the documentation supports it.