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Airway Clearance Devices

Revised: 08-01-2013

  • Overview
  • Eligible Providers
  • Eligible Recipients
  • Covered Services
  • Noncovered Services
  • Authorization
  • Billing
  • Overview

    Airway clearance devices provide self-administered airway clearance for individuals with certain respiratory or neuromuscular conditions.

    Eligible Providers

  • • Medical suppliers
  • • Pharmacies
  • • Home health agencies
  • • Indian Health Services
  • • Federally Qualified Health Centers
  • • Rural Health Clinics
  • TPL and Medicare

    Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare in order to assist recipients for whom MHCP is not the primary payer.

    MHCP quantity limits and thresholds apply to all recipients unless only Medicare coinsurance or deductible is requested.

    Eligible Recipients

    Airway clearance devices are covered for fee-for-service MHCP recipients who meet coverage criteria and are eligible for one of the following programs:

    BB

    MinnesotaCare Plus One

    EH

    Emergency Medical Assistance only with an approved CPC

    FF

    MinnesotaCare Basic Plus

    IM

    Institution for Mental Disease

    JJ

    MinnesotaCare Basic Plus

    KK

    MinnesotaCare Expanded

    LL

    MinnesotaCare Basic Plus Two

    MA

    Medical Assistance

    NM

    State-funded Medical Assistance

    RM

    Refugee

    QM

    Qualified Medicare Beneficiary – (MHCP will cover coinsurance and deductible only)

    Covered Services

  • A7025 (High frequency chest wall oscillation system vest, replacement)
  • • E0480 (Percussor, electric or pneumatic, home model)
  • E0482 (Cough stimulating device, alternating positive and negative airway pressure)
  • E0483 (High frequency chest wall oscillation air-pulse generator system)
  • E0484 (oscillatory positive expiratory pressure device, nonelectric, any type)
  • Nonelectric oscillatory devices are covered for recipients with medical conditions that cause a need for assistance with mucus clearance from the airway.

    Electric or pneumatic percussors are covered for recipients who require chest physiotherapy with the assistance of a mechanical device.

    Cough stimulating devices, also known as In-Exsufflation devices, are covered for recipients with neuromuscular disease which causes a significant impairment of chest wall and/or diaphragmatic movement, and which results in an inability to clear secretions, when standard treatments have failed or are medically contraindicated.

    High Frequency Chest Wall Oscillation (HFCWO) air-pulse generator systems are covered for recipients when standard chest physiotherapy has failed or is medically contraindicated and the recipient has one of the following indications:

  • • Cystic fibrosis
  • • Chronic bronchiectasis, confirmed by radiological scan, and
  • • Daily productive cough for at least 6 continuous months or
  • • More than 2 exacerbations in 12 months requiring antibiotic treatment.
  • • Chronic neuromuscular disease with a history of pneumonia
  • HFCWO replacement vests are covered for use with recipient-owned systems when the original vest is lost, stolen or damaged beyond repair and not covered by a warranty.

    Noncovered Services

  • • HFCWO systems are not covered for recipients who have known cardiac conditions
  • • Intrapulmonary percussive ventilation devices are not covered for any indication because they are investigative.
  • Authorization

    Authorization is always required for cough stimulating devices, HFCWO systems, and replacement vests for HFCWO systems. Submit authorization requests and documentation to the authorization medical review agent.

    Cough Stimulating Devices

    Documentation must include a diagnosis of neuromuscular disease such as multiple sclerosis, spinal muscular atrophy, quadriplegia or muscular dystrophy, and the recipient’s history of conservative treatment and the reason it is not meeting the recipient’s needs or is medically contraindicated. Submit chart documentation.

    HFCWO Systems

    Documentation must include the recipient’s:

  • Diagnosis
  • History of respiratory infections
  • History of chest physiotherapy and the reason it is not meeting the recipient’s needs or is medically contraindicated
  • Submit chart documentation; a checklist is not sufficient to establish medical need.

    Replacement Vests for HFCWO Systems

    Documentation must state the reason the vest needs replacement, and when the warranty period ended.

    Submit authorization requests electronically or on the Minnesota Health Care Programs Authorization Form (DHS-4695-ENG).

    Billing

  • • A high frequency chest wall oscillation air-pulse generator system includes hoses and vest with initial dispensing. Do not bill separately.
  • • A cough stimulating device includes all necessary accessories with initial dispensing. Do not bill separately.
  • • 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 only the deductible / co-insurance on any item for which Medicare made payment, regardless of any MHCP prior authorization.
  • • If the recipient has Medicare, any items for which Medicare denies payment must meet MHCP coverage and authorization requirements.
  • • Shipping and delivery costs are included in the MHCP maximum allowable payment and may not be separately billed to MHCP or the recipient.
  • • Durable medical equipment is expected to serve the recipient for at least 5 years. If a device is stolen or damaged beyond repair, a replacement device may be covered with authorization.
  • Refer to Non-Mobility Equipment Repairs for billing requirements for repairs to durable medical equipment.

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