Ventilator Reimbursement is Still a Hot Topic

Posted on in HME Government Issues

By: Ronda Buhrmester, Reimbursement Team

Ventilators, invasive and non-invasive, have been getting a lot of attention by suppliers and the Medicare contractors such as the DME MACs, RAC, etc. While we all realize there is not a medical policy (LCD) to follow, there is the National Coverage Determination (NCD 280.1) that states “covered for treatment of neuromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure consequent to chronic obstructive pulmonary disease.  Includes both positive and negative pressure types”. 

These are Medicare’s basic rules of thumb that need to be followed as well: 

  1. Rule out the least costly alternative—Why doesn’t the BiPAP meet the patient’s needs?
  2. Make sure there is good, clear, thorough documentation that indicates the medical necessity for the item being ordered

Of course, there is the detailed written order, other supporting documentation, test results, etc., that are also important to obtain prior to delivery.

Documentation is the key for ventilators where the physician needs to “paint the picture.”  Several Medicare contractors have also been auditing these claims, and it doesn’t appear as though they are going to let up.  The recent denials on an NIV (E0464) have stated the following:

“The submitted documentation does not verify that the severity of the beneficiary’s qualifying condition is such that he/she cannot tolerate being off a ventilator for a period of time.”

What does this mean?

A ventilator is necessary for patients whose life is at risk if they are away from the ventilator for any amount of time.  This is why ventilators are categorized as frequent and substantial servicing—life supporting/sustaining equipment.  Medicare wants to know what would happen to the patient if they were not using the ventilator continuously, are they at risk for death?

The bottom line is make sure the medical record indicates that it would be life threatening if the patient discontinues using.  And is especially important to have this information in the progress notes for those patients only using nocturnally.

For further information, reference the article titled, “Correct Coding and Coverage of Ventilators-Revised.”

Face to Face Ruling and More

We know the ventilator codes are included with the Face to Face Ruling (F2F); however the new HCPCS codes have not been updated to the list of codes affected by the ruling.  Until this is clarified, I strongly encourage suppliers to get as much documentation upfront.  Also, make sure that a date stamp is being used that shows it is clear when you, the supplier, have received the DWO and F2F evaluation notes.

With the reduction in reimbursement for January 2016 ($1055.23), it’s so important to make sure that all the necessary documentation is received prior to delivery and all the documentation is complete such as signatures and signature dates on orders, notes, testing, etc.  And it’s important to make sure that it’s clear why a patient needs the ventilator versus the least costly alternative, such as a BiPAP.  Remember the review nurses do not know these patients like a supplier would know the patients. This is why it’s so important to have good, thorough documentation that explains the patient’s condition and the medical need for the ventilator.

New HCPCS Codes

In case you haven’t seen the update, CMS has released the new HCPCS codes for ventilators.  The HCPCS codes go by date of service which means for DOS on or after January 1, 2016 use the new codes listed below. 

The article that included the updated code information is included as well as a quick reference is below.


Discontinue Date

Crosswalk HCPCS Code

















In Summary

Make sure you have implemented internal policies and procedures for ventilators.  And educate your staff on the policies and procedures making sure everyone is on the same page and understands.  Education to referral sources are key as well, working with discharge planners, case managers, social workers, nurses, anyone involved in the patient’s care. 

Don’t hesitate to use an ABN.  With the audit savvy industry, reduction in reimbursement, and with the ventilators included in 2016 OIG work plan, it’s important for suppliers to make sure payment is received for the equipment and services that are provided to patients and not being recouped in an audit. 

Please contact me with any questions.

Ronda Buhrmester, CRT
Reimbursement Specialist
O: 888-665-6518
F: 855-262-3821

[email protected]