It is hard to be positive when…

 

...users of home noninvasive ventilation are an oddity to pulmonologists because they are using a ventilator without being trached AND they live at home.

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…when their choice of a breathing device is determined by the make and models purchased by the area’s home healthcare company.

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…when home healthcare company respiratory therapists assume that a ventilator user could not possibly be in control of his or her health care and related equipment.

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But, recent changes…

 

In the US, there have been changes that affect the process, which in turn affects users of home mechanical ventilation. 

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HCPCS (hick picks) stands for Healthcare Common Procedure Coding System. The numbers are billing codes used by Medicare and monitored by CMS, the Centers for Medicare and Medicaid Services, to provide uniformity of service and payment to the providers. Ventilators are in the Level II HCPCS codes, which are designed to represent non-physician services like ambulance rides, wheelchairs,

walkers, other durable medical equipment.  Level II codes are alphanumeric and five characters long.

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Changes to HCPCS for Ventilators Codes effective January 1, 2016 included adding these two:

• E0465 Home ventilator, any type, used with invasive interface (e.g., tracheostomy tube) 

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

 

The following codes were discontinued effective December 31, 2015: 
  

• E0450 Volume control ventilator, without pressure support mode, may include pressure control mode, used with invasive interface (e.g., tracheostomy tube) 
   

• E0460 Negative pressure ventilator, portable or stationary 
   

• E0461 Volume control ventilator, without pressure support mode, may include pressure control mode, used with non-invasive interface (e.g., mask) 
   

• E0463 Pressure support ventilator with volume control mode, may include pressure control mode, used with invasive interface (e.g., tracheostomy tube) 
   

• E0464 Pressure support ventilator with volume control mode, may include pressure control mode, used with non-invasive interface (e.g., mask)

 

At the same time, reimbursement for the devices was revised, with the range for monthly payment being $1, 055.23 - $869.95.

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In May of 2016, a revised document, Correct Coding and Coverage of Ventilators, was distributed to clarify coding and coverage requirements for ventilators in the Frequent and Substantial Servicing (FSS) payment category. The FSS category is for items for which there must be frequent and substantial servicing in order to avoid risk to the patient’s health, i.e., ventilators. The monthly rental payment for items in this pricing category is all-inclusive meaning there is no separate payment by Medicare for any options, accessories or supplies used with a ventilator. In addition, all necessary maintenance, servicing, repairs and replacement are also included in the monthly rental.

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The document explains its need by stating: “Ventilator technology has evolved to the point where it is possible to have a single device capable of operating in numerous modes, from basic continuous positive pressure (CPAP and bi-level PAP) to traditional pressure and volume ventilator modes. This creates the possibility that one piece of equipment may be able to replace numerous and different pieces of equipment. Equipment with multifunction capability creates the possibility of errors in claims submitted for these items.”

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It further reminds suppliers that FSS payment category prohibits FSS payment for devices used to deliver continuous and/or intermittent positive airway pressure, regardless of the illness treated by the device.

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It stipulates that ventilators are covered for management of neuromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure consequent to chronic obstructive pulmonary. The new guidance removes the prior “imminent death” requirement, which had stated that patients must need a ventilator 24/7 for FSS coverage.

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This has not changed: Medicare will not pay separately for “backup” equipment.  But as before, “Medicare 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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For example, if someone using a wheelchair requires a ventilator mounted on it for use during the day and then another ventilator of the same type for use while in bed, the vent user “may be prone to certain medical complications, may not be able to achieve certain appropriate medical outcomes, or may not be able to use the medical equipment effectively” without two vents. 

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And, work in progress…

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The development of bi-level devices, not used for “life support,” necessitated other HCPCS and requirements established by CMS.  The devices and codes in use today for CPAP (E0601) and bilevel PAP, with and without back up rate, (E0470, E0471), are labeled by CMS as Respiratory Assist Devices or RADs, a term not used in the medical literature or by the Food and Drug Administration (FDA). For over two decades, the term RADs has caused confusion for clinicians, providers and ventilator users.

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The May 2016, Correct Coding and Coverage of Ventilators, acknowledged that some conditions (neuromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure consequent to chronic obstructive pulmonary) are described in the Respiratory Assist Devices Local Coverage Determination and 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.”

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Stating that a person’s medical condition and its specifics should be considered is a start. The current Determination documents contain medically-outdated information, e.g., ignoring the advancements in noninvasive ventilation and its use and utilizing unnecessary/inappropriate tests. 

 

A group of experienced and articulate individuals representing the American Association of Respiratory Care, the American College of Chest Physicians and the National Association for Medical Direction of Respiratory Care have submitted a reconsideration of the current Medicare National Coverage Determination for home ventilators, including bi-level devices to CMS.

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It is under consideration.

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Acceptance and implementation of this well-conceived request would make it easier for those needing considerable hours of ventilation per day to obtain the equipment they need to use noninvasive ventilation and to live at home. The numbers are not large, and the cost isn’t either.

 

Individuals with neuromuscular conditions in need of breathing assistance would definitely benefit.