Non-invasive Ventilator Review

Posted on in Billing/Reimbursement

By: Ronda Buhrmester, CRT, CFm, VGM Group, Inc.

Suppliers of non-Invasive ventilators (NIV) have been circling back with questions about documentation requirements. This means it’s time to review the requirements needed for NIV coverage, particularly because there is not a medical policy (LCD) for the devices.

Here are helpful tips regarding ventilator coverage:

  1. NIVs are 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 or will not work for the patient? What does the NIV have that will work for the patient? This is very important information that must be documented in the patient’s medical record.
  3. Tell the story of the patient (paint the picture). The only information a reviewer has on the patient is the information provided within the documentation. Make sure it is justifying the medical need for the NIV being ordered.

It’s very important to be proactive by reviewing patient files to make sure 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. And, the medical record should not state, “BiPAP was considered and ruled out.” There needs to be more detailed information rather than a generic statement. 

Recently, there has been conversation that Medicare has not been auditing on ventilators or has pulled back. Documentation is KEY when dealing with any home medical equipment. A diagnosis alone is not enough information to support the need. As mentioned earlier, paint the picture, tell the story.

In September the OIG released a report regarding NIVs. The study reported that Medicare paid 85 times more on NIVs in 2015 than in 2009. And, in 2015 the most common diagnosis was chronic respiratory failure, increasing to 85 percent from 2009 when it was only at 29 percent. Neuromuscular disorders were the most common diagnosis in 2009 at 57 percent and decreased to 7 percent in 2015. The study also mentioned that claims for NIV were paid inappropriately for certain diagnosis such as OSA. While the top three companies are known, this does not mean you company is off the hook.

What does this mean? Post-payment audits.

Do not fall into a trap. It bears repeating: Documentation is key when dealing with any home medical equipment, especially when dealing with NIVs. A diagnosis alone is not enough information to support the need. Paint the picture -- tell the story -- of the patient.   

For further questions or comments, please contact:

Ronda Buhrmester, CRT, CFm,
Reimbursement Specialist
[email protected]