CPAP Adherence and Documentation: The 4-Hour/70% Rule and What to Record
As the year draws to a close, clinics and referral sources often see an increase in patient visits, supply requests, and insurance-related questions. For patients using CPAP therapy, this is a key time to ensure compliance is properly documented, especially for those relying on Medicare or private insurance to continue coverage.
Whether you’re a sleep specialist, primary care provider, or DME referral coordinator, this year-end refresher outlines the CPAP compliance requirements, clarifies the 4-hour/70% rule, and provides a clear documentation checklist to help your team stay organized during the busiest season.
What Is the 4-Hour/70% Rule?
Medicare, and most private insurers, require objective proof that a patient is using their CPAP device consistently. The standard benchmark is:
- **At least 4 hours of CPAP use per night
- On 70% of nights
- During a consecutive 30-day period**
This rule helps determine whether the patient is benefiting from therapy and whether coverage for equipment and ongoing supplies can continue.
What Counts as “Objective Usage”?
Compliance data must come directly from the CPAP device, pulled via:
- SD card
- Wireless modem
- Cloud-based platform (varies by manufacturer)
Usage reports should clearly include:
- Number of nights used
- Average hours of nightly use
- Percentage of nights with ≥4 hours of use
- Device model and serial number (when available)
If patients are switching devices or updating equipment, ensure new downloads are available before submitting documentation.
Explore CPAP Devices with Built-In Compliance Tracking
What Should Clinics Document?
Accurate documentation prevents delays, denials, and unnecessary back-and-forth with insurers. Use this practical checklist to keep year-end charting smooth:
CPAP Documentation Checklist for Medicare & Insurance
1. Face-to-Face Evaluation
- Must occur within 6 months of the initial order
- Document sleep apnea diagnosis and symptoms (e.g., snoring, witnessed apneas, daytime fatigue)
2. Objective Usage Data
- 30-day compliance report showing 4-hour/70% adherence
- Include device type, settings, and serial number (if applicable)
3. Patient Education
- Note that the patient was trained on:
- Proper mask fit
- Cleaning/maintenance
- Importance of consistent nightly use
4. Follow-Up Visit
- Required within 90 days of starting therapy
- Record patient’s response to treatment, troubleshooting steps, and adherence barriers
5. Standard Written Order (SWO)
Include:
- Patient name
- Item description (e.g., “CPAP device with heated humidifier”)
- Quantity/frequency of supplies
- Treating practitioner name, NPI, and signature
Incomplete SWOs are one of the most common reasons for delays. Double-check all fields before submitting.
Contact NextGen for Documentation Support
Why This Matters at Year-End
Many patients are trying to reorder supplies before their deductibles reset or FSA/HSA funds expire. Ensuring compliance documentation is complete helps:
- Prevent supply shipment delays
- Reduce denials from Medicare or private insurers
- Support better long-term adherence and outcomes
Medicare PAP Documentation: Common Pitfalls to Avoid
- Missing or incomplete usage data
- Face-to-face evaluation older than 6 months
- No follow-up visit within the required 90-day window
- SWO missing key elements (provider signature, item details, frequency)
- Inconsistent or vague notes about symptoms and response to treatment
A quick chart audit at year-end can prevent most of these issues.
Need help reviewing documentation? Our team at NextGen Medical Supplies can assist with compliance checks and insurance verification.
Contact NextGen for Documentation Support
NextGen Medical Supplies works closely with providers to ensure patient files meet Medicare and insurance requirements. We can assist with:
- Compliance checks
- Usage report review
- Insurance verification
- Supply replacement schedules
New referral? Complete our New Enrollment Form to get started.
