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Sample CPAP Prescription Form
#1
Sample CPAP Prescription Form
Hello all.

Many times I find that members will need to be very specific with their health care provider to obtain equipment that advisors/monitors/administrators recommend. For instance, the "Resmed Airsense 10 Autoset for Her" is likely the most recommended machine on this forum. To assist members in obtaining the equipment that they need and as a matter of fulfilling equipment preference, I have used the very prescription that I was given in order to make a "sample CPAP Rx template". 

My idea of using this template is that the spaces may be filled in by the patient to hand over to the healthcare provider and request that the healthcare provider generate a prescription based on the form. I left the notes field for machine specifics, so in there a patient may write "Dispense Resmed Airsense 10 Autoset for Her, do not substitute" or something along those premises. 

Anyhow, hope this helps out and, of course, please use or modify as you may wish. Everything on the form is accurate to my best knowledge. I wrote the template using Word so it is .docx

Suggestions and critique always welcome.


Attached Files
.docx   CPAP Rx Example.docx (Size: 6.69 KB / Downloads: 75)
Jesse


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#2
RE: Sample CPAP Prescription Form
Also for patients in the USA, I have two things to add ... I mean not to that document itself, but separate information.

First, here's a link to a PDF at the Resmed web site listing the HCPCS codes for everything along with the reimbursement fee schedule as of 2017.

(PDF) "CMS Reimbursement 2017 - ResMed"

Second, here is the Medicaid supply replacement schedule, which is relatively stingy compared to Medicare & private insurance but still adequate as far as it goes.  However, the big gotcha is that after a new patient is issued a machine and a mask, none of this applies (there are no supplies provided) until the 10-month machine-rental period is over and the patient owns the machine.  During the first 10 months, Medicaid patients have to buy their own supplies.

Headgear:  1 every 6 months
Chin strap:  1 every 6 months
Full-face mask:  1 every 6 months
Full-face cushion:  1 every year
Nasal mask:  1 every 6 months
Nasal cushion:  2 every 2 months
Nasal pillow:  2 every 2 months
Standard tubing:  1 every 6 months
Heated tubing:  1 every 6 months
Disposable filters:  2 every month
Non-disposable filters:  1 every 6 months
Water chamber:  1 every 6 months
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#3
RE: Sample CPAP Prescription Form
(05-30-2018, 06:32 PM)Fats Drywaller Wrote: Also for patients in the USA, I have two things to add ... I mean not to that document itself, but separate information.

First, here's a link to a PDF at the Resmed web site listing the HCPCS codes for everything along with the reimbursement fee schedule as of 2017.

(PDF) "CMS Reimbursement 2017 - ResMed"

Second, here is the Medicaid supply replacement schedule, which is relatively stingy compared to Medicare & private insurance but still adequate as far as it goes.  However, the big gotcha is that after a new patient is issued a machine and a mask, none of this applies (there are no supplies provided) until the 10-month machine-rental period is over and the patient owns the machine.  During the first 10 months, Medicaid patients have to buy their own supplies.

Headgear:  1 every 6 months
Chin strap:  1 every 6 months
Full-face mask:  1 every 6 months
Full-face cushion:  1 every year
Nasal mask:  1 every 6 months
Nasal cushion:  2 every 2 months
Nasal pillow:  2 every 2 months
Standard tubing:  1 every 6 months
Heated tubing:  1 every 6 months
Disposable filters:  2 every month
Non-disposable filters:  1 every 6 months
Water chamber:  1 every 6 months

Thank you for the extra information. I found an error in the code for bilevel w/o backup rate. As written is E407. Correct code is E470. I did not have a reference for the codes as I took them from my form that someone else had authored. My form was a little sloppy so I cleaned it up but didn't check the information. Thanks again.
Jesse


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#4
RE: Sample CPAP Prescription Form
Weird

Ive been using my swift fx for 2 years now, why do you need to change them?

Also whats the Non-disposable filter?
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#5
RE: Sample CPAP Prescription Form
(05-31-2018, 02:44 AM)crowtor Wrote: Weird

Ive been using my swift fx for 2 years now, why do you need to change them?

Also whats the Non-disposable filter?

The Dreamstation series machines have a cartridge with a prefilter that is rinsable and is intended to be used for 3 months before replacement. The disposable filter clips on to the cartridge. It's actually a nice little setup in my opinion. The system one series had a black foam filter and a disposable filter tucked in behind it, not great but okay. 

As for changing cushions on swift fx, I can only relate. I like to go for as long as possible on a cushion myself. Usually I have to fight leaks it seems before it wears out. Can't honestly say I've wore one out, just get leaks under my lip.
Jesse


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#6
RE: Sample CPAP Prescription Form
JesseLee,

Kudos on this. Will be very useful to all of us at some point, I'd think.

As an aside on Medicaid (it may only be from the Commonwealth of PA perspective); I think Medicaid is handled as the secondary insurance. I was issued United Healthcare and Medicaid from county/state assistance. I got the ASV and supplies with this insurance combo paying 100% due to being disabled.
Dave

I'm not a doctor in real or fictional life. My posts include opinions based upon user experience regarding CPAP therapy and should not be considered medically professional direction or advice. Even a 1,000 mile trip requires a good first step. My recommended first steps include getting good walking shoes, 1 great cup of coffee, and a good GPS.

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#7
RE: Sample CPAP Prescription Form
I believe medicaid is different rules and coverage from state to state.
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#8
RE: Sample CPAP Prescription Form
I couldn't go back and edit the original post with the attachment and I have corrected an error with the bilevel coding. 

This is the corrected document to reflect correct coding. Changed E0407 to correct code E0470.

If admin can replace this document, please do and thanks for the help!

Thanks


Attached Files
.docx   CPAP Rx Example.docx (Size: 6.69 KB / Downloads: 14)
Jesse


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#9
RE: Sample CPAP Prescription Form
Jesse,
I looked at your form and it is impressive.  I've have one question,  Shouldn't it be "Patient Name" instead of "Customer Name"?

signed,
Anal in Georgia Big Grin
Crimson Nape
Apnea Board Moderator
www.ApneaBoard.com
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#10
RE: Sample CPAP Prescription Form
(06-01-2018, 10:12 AM)Crimson Nape Wrote: Jesse,
I looked at your form and it is impressive.  I've have one question,  Shouldn't it be "Patient Name" instead of "Customer Name"?

signed,
Anal in Georgia Big Grin

Always has to be someone that nitpicks.  Big Grin

My brother in law is heading out today from Kentucky to take his new job in Cumming on Monday. He's a real jerk. If you send me your address I'll make sure he gets a copy to hand deliver to you.  Big Grin 

j/k

The updated form is attached.  Thanks


Attached Files
.docx   CPAP Rx Example 3.docx (Size: 6.69 KB / Downloads: 10)
Jesse


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