|Photo by David Stuckman|
Sleep technologists ordinarily spend 1,000 to 2,000 hours per year in face-to-face contact with patients trying out PAP therapy. Often, they know sleep patients as well as if not better than other providers who care for them. When effectively trained, sleep techs can engage patients to learn about their motivations, frustrations, and anxieties about PAP therapy. They also serve as an early warning system embedded in the sleep lab to detect barriers to adaptation. Few other health care professional can match the nightly experiential interactions between sleep techs and patients, which often prove key to successful PAP therapy outcomes.
Why then has the sleep medical community abided by a system created by government, insurance carriers, and durable medical equipment companies (DMEs) in which sleep techs are restricted from helping patients to learn to use PAP therapy during the daytime? When I was researching this question during the past decade, the most frequent answers offered were that sleep techs are not:
- licensed health care professionals,
- respiratory therapists,
- eligible for reimbursement for their own services.
While these points are correct, it strikes me as a failure of imagination to have not found a way to employ the daytime skills and talents of sleep technologists to help sleep patients in their quest to adhere to PAP therapy. The only caveat I’ve discovered is that many sleep medicine physicians direct sleep techs to operate PAP clinics to assist patients—free of charge! By the way, the fact that free PAP clinics have sprung up across our country at a sizeable number of sleep medical centers informs us a great deal about the quality of services patients receive at DME home care companies.
My curiosity about the role of sleep techs peaked after opening a private, community-based sleep medical center in Albuquerque, NM—Maimonides Sleep Arts & Sciences. Having spent the previous 15 years exposed to academic sleep medicine, in the real world I rapidly gained a clearer perspective on the untapped potential for sleep techs in the daytime setting and just as rapidly saw my frustration lap my curiosity upon the realization that scant attention or action addressed this issue. At the 2003 APSS meeting, my research on the topic proved disappointing and unrevealing except for one critical pearl: “Never underestimate the value of discussing new ideas with insurance carriers including Medicare officials.”
For 6 months, I broached the topic with national, regional, and local Medicare and DMERC officials as well as directors at other insurers. Surprisingly, I found a lot of interest in my three main points: sleep techs have a wealth of unique experience, often demand less compensation than respiratory therapists, and clearly have skills to coach patients who attempt PAP therapy. Nearly every official was receptive to my closing question: “Shouldn’t the system find a way to engage these talented health care technologists to improve quality of care, enhance outcomes, and do so in potentially cost-effective ways?” A few officials researched the topic, but no one offered a solution until my discussions intensified with my regional Medicare medical director.
Soon thereafter, we focused on the established concept of “services performed by ancillary personnel under the general supervision of a qualified Medicare provider.” This rule authorizes sleep techs to conduct procedures (eg, sleep tests) under the direction of sleep physicians. Thus, we concluded sleep techs could work during the daytime with sleep patients if the context was devised as a procedure. From there, we reviewed existing CPT codes and learned that 95807 reflected a simplified attended sleep test (four sensor minimum), which had already been deemed a tool to enhance PAP therapy compliance. This code provided the framework to develop our new protocol, the PAP-NAP, in which the sleep tech would have the opportunity to spend 2 to 5 hours with the patient during the daytime to provide behavioral assessment and coaching as well as physiological exposure to pressurized airflow. In the first half, the patient receives advanced desensitization steps; then, in the second half, the patient uses PAP therapy for up to 2 hours or longer to unequivocally “taste” the experience.
Developing the PAP-NAP and training sleep techs in the procedure were a collaborative effort involving myself and several staff, and now training is conducted by myself and our lab manager and consists of three basic components: (1) rapport building; (2) imagery techniques; and (3) assessment of emotional responses. Rapport building and emotion work are measured in our tech hiring process, and all three components are part of routine tech training for all patient interactions in the sleep lab. The three most common skills techs exhibit to show competency include exceptional listening capacity coupled with the use of humor to diminish anxiety; ability to navigate patients through basic imagery exercises (guided daydreaming) and to spot patients with unstable imagery aspects (eg, posttraumatic stress disorder [PTSD] or nightmare patients) that require immediate sleep specialist intervention; and empathy in the pragmatic form of repeatedly asking patients, “How are you feeling?” and “How are you doing?” and responding appropriately to the situation. In our experience, sleep medicine specialists or behavioral sleep medicine specialists in combination with their lab managers can provide this training.
When developing and then applying the PAP-NAP in 2004, we were unsure whether the procedure would be reimbursable, but our discussions with Medicare officials led us to believe there were no reasons to deny payment. However, due to its abbreviated duration, we were concerned the 95807 code might reflect an overpayment of services. In our final discussion with Medicare officials, we agreed to attach the “52” modifier (CPT 95807-52) denoting the PAP-NAP as a short study. Since its inception, we have conducted nearly 200 PAP-NAPs and received reimbursement for each one.
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In 2008, in the Journal of Clinical Sleep Medicine, we published our first data on the PAP-NAP procedure along with details on how to organize the protocol in the sleep medical center environment. The study demonstrated benefits to insomnia patients with comorbid sleep apnea and increased adherence to PAP therapy. Since then, we have been applying the PAP-NAP procedure to various types of anxious patients including those with cardiac conditions, moderate claustrophobia, and PTSD as well as vulnerable elderly and adolescent patients.
We have been pleased with interest in the procedure, having received e-mails and phone calls from across the country. At APSS 2009, it was gratifying to learn about a sleep medical center in Arizona that has conducted more PAP-NAPs than our own center and with the same successful outcomes regarding enhanced care and reimbursement. We are hopeful this new procedure using existing CPT codes will create the opportunity for sleep techs to provide more hands-on coaching to sleep patients in cost-effective ways.
Barry Krakow, MD, is the author of Sound Sleep, Sound Mind, principal investigator at Sleep & Human Health Institute, and medical director at Maimonides Sleep Arts & Sciences Ltd (www.sleeptreatment.com), and blogs at www.sleepdynamictherapy.com. He can be reached at firstname.lastname@example.org.