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Ventilator v/s Bi Level PAP Devices. DME MACs Clarify Requirements

WASHINGTON – In highly anticipated clarifications on coding and coverage requirements for ventilators, the DME MACs have acknowledged that coverage for the product category isn’t quite black and white.

While the National Coverage Determination stipulates that vents are covered for neuromuscular diseases, thoracic restrictive diseases and chronic respiratory failure, the DME MACs acknowledge that these disease groups overlap conditions described in the local coverage determination for respiratory assist devices.

“Each of these disease categories are conditions where the specific presentation of the disease can vary from patient to patient,” the DME MACs state in a joint publication published May 5. “For conditions such as these, the specific treatment plan for any individual patient will vary. 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.”

The DME MACs also reiterate coding requirements for vents. As of Jan. 1, 2016, all products classified as vents must be billed using E0465 (invasive) or E0466 (non-invasive). Products previously assigned to E0450 and E0463 must use E0465; those previously assigned to E0460, E0461 and E0464 must use E0466.

The DME MACs reminded providers that vents are classified in the frequent and substantial servicing (FSS) payment category, while CPAP and bi-level PAP items are in the capped rental payment category, and that policy prohibits FSS payment for devices used to deliver continuous and/or intermittent positive airway pressure, regardless of illness.

“This means that products currently classified as E0465 or E0466, when used to provide CPAP or bi-level PAP therapy, regardless of the underlying medical condition, may not be paid in the FSS payment category,” they state.

The DME MACs also say:
•The upgrade billing provisions may not be used to provide a vent for conditions described in the PAP or RAD LCDs. Upgrade billing across different payment categories—again, vents are classified in the FSS payment category, while CPAP and bi-level PAP items are in the capped rental payment category—is not possible.
•Medicare does not cover spare or back-up equipment, but it will make a separate payment for a second piece of equipment if it is required to serve a different medical purpose that is determined by the beneficiary’s medical needs.

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