Ramblings of a sleep apnea e-patient

The CPAP machines that most people are prescribed fall into the insurance code category E0601. The second most common insurance code is E0470 for BiPAP machines. This insurance billing code is what is used by the DME to get paid by your insurance company when you rent or buy a machine through that DME. E0601 and E0470 cover quite a number of different machines:

  • E0601
    • CPAP – One pressure setting. Many have limited exhale pressure relief settings that can reduce pressure as much as zero to three centimeters of pressure during exhale.
      • Compliance-Data-only CPAP – the least expensive, no-frills machine, one pressure setting.
      • Compliance-and-Extended Data CPAP – an alternative machine that records not only compliance data but also extended data – a better alternative when first starting out, but not the best.
    • APAP – Two pressure settings: minimum and maximum constant pressures. Constant pressure is allowed to drift between an upper and lower limit depending on feedback recorded by the machine. As the body needs more pressure, current constant pressure is increased. Likewise, if less pressure is deemed better, the constant pressure is slowly reduced. Most APAPs additionally have limited exhale pressure relief settings that can reduce pressure as much as zero to  three centimeters of pressure during exhale.
      • Compliance-Data-only APAP – No-frills APAP’s are often lightweight travel machines for people in-the-know about their pressure needs. Sometimes it’s nice to have a travel machine that you don’t have to worry about if it gets lost in transit. This machine will anticipate needs for raising or lowering pressure slowly over time as your pressure needs change during the night.
      • Compliance-and-Extended Data APAP – The pinnacle and hence most expensive of the E0601-billable machines.
  • E0470
    • BiPAP – Two pressure settings: inhale and exhale. This is for people using higher pressures. Some BiPAP’s come with additional exhale pressure relief settings that can help shape the relief response pressure curve of a traditional BiPAP.
      • Compliance-Data-only BiPAP – While they used to be fairly common, I’m not sure these are available anymore. You might still be able to buy one of these from Second Wind or another used equipment vendor. You’ll likely spend very little for a used machine like this. This is a last resort for the BiPAP user.
      • Compliance-and-Extended Data BiPAP – Because you’re already having to spend a lot more for any E0470 machine, this appears to be the minimum buy-in for most BiPAP’s today.
    • Variable BiPAP – Three pressure settings: Inhale, Exhale and Max. This allows the inhale and exhale  pressure to slide up and down based on recorded feedback during the night. Many of these machines have additional capabilities that are beyond the scope of this post.
  • All Machines
    • Most machines today include “ramp” technology. For some people, the therapeutic pressure can seem uncomfortable, so the starting pressure is ramped from a more comfortable pressure over a set number of minutes at the beginning of the sleep session to the therapeutic pressure that keeps airways open. Ramp is fairly useless for low pressures, but this too can be a personal preference.

Let’s just look at the most common insurance billing code, E0601. There can be a huge difference in the cost of a no-frills compliance-data-only CPAP and a full-data APAP.  The amount of money the DME gets from the insurance company is the same whether you acquire the cheap machine or the more expensive machine. For that reason alone, many DME’s would rather sell you the cheapest machine. They take advantage of the fact that most people don’t do the research to find out what machine would be best for them.

My first machine was a Respironics M-Series Pro with CFlex. This was a Compliance-and-Extended-Data CPAP. I had to buy the software from Australia because they weren’t selling it any longer in the US. On my follow up visit to discuss the sleep study, my sleep doctor said he was a little leary of giving me a data-capable machine, but I convinced him. When I went to my first meeting with the RT at the DME, she said she would be able to get me the machine I wanted, but when I showed up to receive the machine, I was handed the M-Series Plus, which only records compliance data. I told her I knew it wasn’t the right machine. She said what I wanted wasn’t available. It took a couple days of convincing. I told the doctor I’d go somewhere else if I didn’t get the machine I wanted. The same day, the machine I wanted magically became available from the DME, so I was fine with that.

I learned a lot about CPAP therapy by looking at the available data. It gave me a sense of empowerment over my CPAP therapy. Empowerment and knowledge are what make any health regime useful.

It was only later, after more research and talking with other CPAP users that I found out about APAP and the benefits of using one of these. While any APAP can be set as a CPAP, APAP seems generally better because pressure needs change depending on whether you’re sleeping on your side, back or belly. APAP’s can sense your pressure needs and adjust up or down accordingly. CPAP does not – it only provides the single pressure setting.

My advice is that if you are diagnosed as needing CPAP, acquire the data-capable APAP machine. Yes, it’s a more expensive machine. If your insurance covers it, you’ll likely pay the same whether you get the crummy data-less CPAP or the svelte data-capable APAP. It’s worth buying the APAP, even if the DME wants to bully you into getting cheapest CPAP. Likewise, if you have to have BiPAP, get the the Auto/variable BiPAP for the same reasons. Take charge of your therapy. Don’t let the DME bully you.

Glossary:

  • CPAP – Constant Positive Air Pressure – also the machine responsible for providing it. CPAP is often used as the all-inclusive term for CPAP, APAP, BiPAP, etc.
  • APAP – Automatic Positive Air Pressure – variable pressure based on bodily feedback.
  • BiPAP – Bi-Level Positive Air Pressure
  • DME – Durable Medical Equipment – also the vendor of the same.
  • RT – Respiratory Therapist.
  • Compliance Data – A string of number/characters on the data window of your CPAP machine that tells your DME/Insurance company that you are using the machine four or more hours every night.
  • Extended Data – Additional data recorded by the machine about how well you probably slept indicated by how well you breathed, how many interruptions and leaks you had, their durations, and when they occurred.

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