Ventilator Coding and Coverage Requirements Clarified

Posted on in Billing/Reimbursement, HME Government Issues

By: Ronda Buhrmester, VGM & Associates

A joint DME MAC publication was released May 5 regarding ventilators. Joint publication means that what is included in the publication covers all four jurisdictions: A, B, C and D.

Basically, the article included two revisions:

The first revision was to remove the “old” HCPCS codes that were used prior to Jan. 1, 2016. For claims with a date of service on or after Jan. 1, 2016, all products classified as ventilators must be billed used one of the following codes:

  • E0465 – Home ventilator, any type, used with invasive interface (e.g., tracheostomy tube) or
  • E0466 – Home ventilator, any type, used with non-invasive interface (e.g., mask, chest shell)

The second revision regards coverage. According to the joint publication:

These ventilator-related disease groups overlap conditions described in the respiratory assist device (RAD) LCD used to determine coverage for bi-level PAP devices. Each of these disease categories are conditions where the specific presentation of the disease can vary from patient to patient. For conditions such as these, the specific treatment plan for any individual patient will vary as well. Choice of an appropriate treatment plan, including the determination to use a ventilator vs. a bi-level PAP device, is made based upon the specifics of each individual beneficiary’s medical condition. In the event of a claim review, there must be sufficient detailed information in the medical record to justify the treatment selected.

Also, if you recall from the initial article in April 2014 and the revised article on Jan. 1, 2016, there was a great discussion about how a ventilator is for life-threatening situations, where interruption of respiratory support would quickly lead to serious harm or death. This was removed from the current article.

Click here to view the entire joint publication.

What does this mean? First, this is good news for our supplier industry. However, I caution suppliers there still needs to be good, thorough documentation as to why a patient needs a ventilator, especially a non-invasive ventilator, instead of a least costly alternative such as a bi-level RAD, which still must be considered or tried and ruled out. Remember, a review nurse only knows the patient by the documentation provided during an audit. The picture still needs to be clearly painted to justify the medical need. 

Use the “why and what.” Why is a ventilator the appropriate treatment for this patient? What is going on with the patient that a ventilator is medically necessary? Why isn’t bi-level treatment going to work for this patient? What did not work for the patient, if tried, on bi-level?

Please contact me with questions. And, I do hope to see you at Heartland this year!

Ronda Buhrmester, CRT
O: 888-665-6518
C: 855-493-5440
[email protected]