Ventilators are used by recipients without spontaneous breathing or with limited or intermittent spontaneous breathing. Continuous Positive Airway Pressure (CPAP) and Bi-level Positive Airway Pressure (BiPAP) devices are used for spontaneously breathing recipients who require ventilation assistance.
The following providers may provide ventilators:
• Medical suppliers
• Pharmacies (CPAP and BiPAP equipment only)
• Home health agencies
• Indian Health Services
• Federally Qualified Health Centers
• Rural Health Clinics
Because ventilators are life-sustaining equipment, providers must:
• Conduct an in-home environmental assessment to confirm the patient’s residence will safely accommodate the ventilator and auxiliary equipment, along with routine household appliances and activities. The assessment includes, but is not limited to, checking for grounded electrical outlets and functional smoke detectors, emergency protection planning and escape route planning.
• Train the recipient and caregivers in proper use of the ventilator, including infection control, alternative ventilation, and emergency ventilation procedures
• Have 24 hour per day support for troubleshooting and ventilator exchange due to unresolved malfunction
• Ensure critical alarms are appropriately set on the ventilator
• Ensure a backup alarm system is in place for when the patient is not directly observed by a fully trained caregiver
• Perform periodic maintenance at least as frequently as recommended by the manufacturer
Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare in order to assist recipients for whom Minnesota Health Care Programs (MHCP) is not the primary payer.
MHCP quantity limits and thresholds apply to all recipients unless only Medicare coinsurance or deductible is requested.
Respiratory equipment and related supplies are covered for eligible recipients with a diagnosis of restrictive thoracic disorders, severe chronic obstructive pulmonary disease, central sleep apnea, neuromuscular respiratory insufficiency, or other diagnoses which require ventilation assistance.
The following services are covered:
• Codes: E0465, E0466, E0470-E0472, E0601, A4604, A7027-A7039, A7044-A7046
• BiPAP device for recipients with medical conditions that require ventilation assistance if the recipient has spontaneous respiration
• CPAP device for recipients with breathing disorders other than obstructive sleep apnea with authorization
• BiPAP device with backup rate for recipients with obstructive sleep apnea and co-existing breathing disorders. Both diagnosis codes must be on the claim
• CPAP or BiPAP device with authorization if the recipient has a third party insurance that requires purchase rather than rental
• Rental of a ventilator for recipients who have been determined by a physician to need a ventilator. Both a portable and a stationary ventilator may be covered when documentation establishes that a portable ventilator alone does not meet the recipient’s needs
• For recipients with obstructive sleep apnea (OSA), refer to the Positive Airway Pressure for OSA policy
Back-up ventilators are not covered because it is a duplication of equipment.
The following require authorization:
• Authorization is required for all purchases of CPAP or BiPAP devices. Documentation must show that the primary payer requires purchase rather than rental of the device.
• Authorization is required for maintenance service agreements for E0470–E0472. Maintenance service agreements are not available for E0601.
• Authorization is required for rental of a CPAP device for indications other than obstructive sleep apnea. Documentation must show that respiratory equipment is medically necessary, and that the recipient does not require a BiPAP device or ventilator.
• Authorization is required for a rental of a BiPAP device without backup feature for treatment of obstructive sleep apnea. Documentation must show a failed CPAP trial or medical contraindication to a CPAP device.
• Authorization may be approved for supplies in excess of MHCP limits when necessary. The medical review agent will not approve authorization of supplies needed due to willful or careless destruction by a recipient unless documentation shows that the destruction was because of the physical or mental impairment of the recipient.
Submit authorization requests and required documentation to the authorization medical review agent.
Refer to the Medical Supply Coverage Guide (PDF) for coverage information and limits on supplies not specified here.
When dispensing a device that can provide multiple levels of treatment (a device with CPAP, BiPAP or ventilator modes) to a recipient, billing must be based on the recipient’s medical condition. Providers must have documentation from the prescriber that is sufficient to support the level of service for which the supplier is billing.
Included with initial CPAP or BiPAP dispensing:
• Carrying case
• CPAP valve (if separate from mask)
• Disconnection alarm (if needed)
• Instruction manual
• Power cord
• Permanent circuits
• Swivel adapters
Separately billable at initial CPAP or BiPAP dispensing:
• Head gear
• Humidification device
Included with ventilator rental:
• Breathing circuits
• Carrying case
• Electric cord
• Exhaustion valves
• High, low and disconnect alarms
• High pressure hoses
• IMV devices
• PEEP valve
• Pressure manometers
• Spirometer, any kind
• Water traps
Separately billable from ventilator rental:
• Manual resuscitation bags
• Oxygen analyzers
Other billing guidelines:
• Ventilators have been determined by the Centers for Medicare and Medicaid Services (CMS) to require frequent and substantial servicing. MHCP will not purchase ventilators, and rented ventilators do not convert to purchase.
• CPAP and BiPAP equipment is capped rental only unless a primary payer requires purchase and authorization is obtained.
• Use X12 Batch or MN–ITS 837P Professional electronic claim.
• Report the ordering provider in the Other Provider Types section of the MN–ITS Interactive claim.
• If the recipient has Medicare, MHCP will pay the deductible or co-insurance on any units for which Medicare made payment, regardless of any MHCP authorization.
• Any items or units for which Medicare denies payment must meet MHCP quantity, coverage, and authorization limits.
• Bill the first three months of CPAP or BiPAP equipment using modifier RR and modifiers KH, KI or KJ as appropriate.
• When billing for rental of CPAP or BiPAP equipment after the first three months, use modifiers RR, modifiers KH, KI or KJ as appropriate and modifier KX if documentation in the file supports that the supplier has verified recipient compliance with treatment. Do not use modifier KX if the supplier has not verified compliance, or if the supplier has information that the recipient is not compliant with treatment except as described above.
• MHCP will deny claims for CPAP or BiPAP rental past the first three months, unless the RR and KX modifiers are present to indicate recipient compliance with treatment.
• Shipping and delivery costs are included in the MHCP maximum allowable payment. Do not bill either MHCP or the recipient separately for these costs.
• Refer to Non-Mobility Equipment Repairs for billing requirements for repairs and maintenance to patient-owned equipment.
• CPAP and BiPAP equipment is expected to serve the recipient for at least five years. If a device is stolen or damaged beyond repair, a replacement device may be covered with authorization. Submit a claim with a Claim Attachment Criteria explaining why a replacement is required.
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