Ventilator Coding Requirements Revised in Favor of Patients

WASHINGTON, D.C. (May 6, 2016)—As anticipated last week, the DME MACs collectively released revised coding and coverage requirements for ventilators in the Frequent and Substantial Servicing (FSS) payment category. The new guidance removes the imminent death criteria from the coverage, which is now applicable under the following conditions:

Neuromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure consequent to chronic obstructive pulmonary disease.

The announcement, which can be found here, explains, “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.”

The announcement also discusses issues related to upgrades and conditions needed to authorize payment for a second ventilator, which can only occur in cases of medical necessity, and not for spare/back-up equipment.

AAHomecare has been actively working with our members and other stakeholders in the respiratory care sector to pursue relief on ventilator clinical requirements. This revised coding and coverage is a direct result of industry, clinical groups, consumer groups, manufacturers and suppliers engaging CMS and the DME MACs to advocate for needed adjustments to the medical necessity requirements for these essential products.

AAHomecare will provide further analysis upon review.

Visit aahomecare.org for more information.