NIV Prepayment Review in Jurisdiction A and D, now Jurisdiction C! Are you ready?

Posted on in Billing/Reimbursement

This article was published in our newsletter recently. I felt that it was time to republish it with news that Jurisdiction C is going to be performing reviews. Jurisdiction B are you are ready? The reviews have been initiated due to the increase in claims submitted for this code. It’s important for all DME suppliers to be prepared in all Jurisdictions that provide this product be prepared. Here are helpful tips regarding ventilator coverage:

  1. Generally covered for treatment of neuromuscular disorders, thoracic restrictive diseases, or chronic respiratory failure secondary to COPD.
  2. Make sure the least costly alternative has been considered or tried and ruled out. Why is a BiPAP insufficient? This is very important information to that must be documented in the patient’s medical record.
  3. The E0464 is one of the HCPCS codes under the ACA 6407 Face to Face ruling that was implemented July 1, 2013.
There are two elements to the F2F ruling:
  • Detailed Written Order
    • The detailed written order needs to be completed and obtained by the supplier prior to delivery.
    • Make sure the order has been date stamped in a method that it’s clear it was “received by ABC supplier.”
    • Make sure the order was written within six months of the F2F encounter.
  • Face to Face Encounter
    • Needs to be obtained prior to delivery with a date stamp received.
    • The medical record needs to include why this item is medically necessary.
    • If the NP, PA, or CNS performed the F2F visit, then the treating physician needs to sign off on the F2F encounter.
4. The detailed written order needs to include the following elements:
  • Patient’s name
  • Treating practitioner’s name (printed or typed)
  • Start date of order – if start date is different than order date
  • Order for ventilator with description/brand/model/ and settings
  • Practitioner signature
  • Practitioner signature date and NPI
  • Length of need
  • Frequency of use
It’s very important to be proactive by reviewing patients files to make the necessary information has been obtained. Does the medical record state that BiPAP has been tried or considered and ruled out? If the medical record states something like, “patient is on BiPAP and seems to be doing well” and then an NIV is ordered, you will get a denial. The medical record must rule out BiPAP therapy! Also it’s important to be prepared and organized when submitting requested documentation by including a table of contents, numbering all the pages, and underline or asterisk important information. Make sure to track these reviews and copy all the information that has been submitted. Here are some resources for your use.

Correct Billing of Non-Invasive Interfaces Used in Conjunction with HCPCS Code E0472 Joint DME MAC Publication

Correct Coding and Coverage of Ventilators Joint DME MAC Publication

Widespread Prepayment Probe for HCPCS Code E0464

  For further questions, please contact: Ronda Buhrmester, CRT Reimbursement Specialist Respiratory equipment, face to face ruling, and general DME O: 888-665-6518 F: 855-262-3821 Email: [email protected]