Respiratory Equipment
Overview
Ventilators are used by members 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 members who require ventilation assistance.
Eligible Providers
The following may provide respiratory equipment:
Ventilators are life-sustaining equipment. Providers must perform the following:
TPL and Medicare
Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare to assist members for whom Minnesota Health Care Programs (MHCP) is not the primary payer.
MHCP quantity limits and thresholds apply to all members unless only Medicare coinsurance or deductible is requested.
Refer to the Medicare and Other Insurance section of the MHCP Provider Manual for more information.
Eligible Members
Respiratory equipment and related supplies are covered for eligible Medical Assistance and MinnesotaCare members 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.
Refer to the Positive Airway Pressure for Treatment of Obstructive Sleep Apnea section of the MHCP Provider Manual for members with obstructive sleep apnea.
Covered Services
Codes: A4604, A4605, A4614-A4620, A7027-A7039, A7044-A7047, E0465-E0468, E0470-E0472, E0550, E0555, E0560, E0600, E0601, E0605, E0606
MHCP covers the following equipment:
Continuous Positive Airway Pressure (CPAP) Devices
CPAP devices (E0601) are covered with authorization for members with breathing disorders other than obstructive sleep apnea. Documentation must articulate the member’s diagnosis, medical necessity, clinical history, respiratory symptoms, and why other respiratory treatments do not satisfy the member’s medical needs. Documentation must indicate that the member does not require a BiPAP device or ventilator. Refer to the Positive Airway Pressure for Treatment of Obstructive Sleep Apnea section of the MHCP Provider Manual for members with obstructive sleep apnea.
CPAPs are capped rental items only. Authorization is required for purchase when the primary payer requires purchase rather than rental. MHCP covers one CPAP device per five years.
The following items are included with initial CPAP dispensing:
The following items are separately billable at initial CPAP dispensing:
Bi-level Pressure Respiratory Assist (BiPAP) Devices
BiPAP devices without backup rate (E0470) and with backup rate (E0471, E0472) are covered for members with medical conditions that require ventilation assistance for 12 hours or less each day if the member has spontaneous respiration. The member’s diagnosis must be on the claim. Authorization is not required, unless requesting quantities over the MHCP quantity limit. MHCP covers one BiPAP device per five years.
Authorization is required for BiPAPs without backup rate (E0470) for members only with obstructive sleep apnea. Documentation must articulate medical necessity, clinical history, respiratory symptoms, CPAP trial failure or medical contraindication, and why other respiratory treatments do not satisfy the member’s medical needs. MHCP does not cover BiPAPs with backup rate (E0471, E0472) for members only with obstructive sleep apnea.
BiPAPs with backup rate (E0471, E0472) are covered for members with obstructive sleep apnea and coexisting respiratory conditions or breathing disorders. The member’s diagnoses must be on the claim. Documentation must articulate the member’s diagnoses, medical necessity, clinical history, and respiratory symptoms.
BiPAPs are capped rental items only. Authorization is required for purchase when the primary payer requires purchase rather than rental.
The following items are included with initial BiPAP dispensing:
The following items are separately billable at initial BiPAP dispensing:
Ventilators
Home ventilators (E0465, E0466) are covered for members with respiratory conditions or diseases that restrict breathing and who have been determined by a physician to need a ventilator. Documentation must articulate the member’s diagnosis, clinical history, and respiratory symptoms.
Dual-function ventilators (E0468) are covered for members with respiratory conditions or diseases that necessitate ventilation and cough stimulation. The dual-function ventilator has the capability of completing the cough stimulation function. HCPCS code E0468 must be billed without another ventilator rental and includes accessories, components, and supplies for all functions. HCPCS codes encompassed by HCPCS code E0468 are not separately reimbursable. Refer to the Airway Clearance Devices section of the MHCP Provider Manual for members who only require a cough-stimulating device.
Multifunction ventilators (E0467) are covered for members who would otherwise require both a portable and a stationary ventilator but can be served by the multifunction ventilator alone. The multifunction ventilator has the capability of completing the aspiration, cough stimulation, drug nebulization, and oxygen concentration functions. HCPCS code E0467 must be billed without another ventilator rental and includes accessories, components, and supplies for all functions. HCPCS codes encompassed by HCPCS code E0467 are not separately reimbursable unless the client has oxygen needs of more than six liters per minute. If a member is utilizing the oxygen feature of the multifunction ventilator, providers must adhere to the requirements of the oxygen policy found on the Oxygen Equipment section of the MHCP Provider Manual, including supplying 12 hours of emergency gaseous oxygen at no additional charge.
Refer to the Ventilators Table of this MHCP Provider Manual section for information on which HCPCS codes are included in payment for dual-function and multifunction ventilators.
Ventilators are rental items only. Ventilators have been determined by the Centers for Medicare & Medicaid Services (CMS) to require frequent and substantial servicing. MHCP will not purchase ventilators, and rented ventilators do not convert to purchase.
Authorization is required for second ventilators. MHCP covers portable and stationary ventilators if substantial documentation establishes that a portable ventilator alone does not meet the member’s needs. Examples include the following:
The following items are included with ventilator rentals:
The following items are separately billable from ventilator rentals:
Respiratory Suction Pumps
Respiratory suction pumps (E0600) are covered for members who require upper respiratory oral pharyngeal and tracheal suction to remove mucus and other secretions from the airway.
Respiratory suction pumps are capped rental or purchase items. MHCP covers one pump per five years.
Authorization is required for second respiratory suction pumps. A portable pump may function as a stationary pump. MHCP will only pay for one portable or stationary respiratory suction pump. MHCP will not cover both portable and stationary pumps, unless substantial documentation establishes that a portable pump alone does not meet the member’s needs.
Miscellaneous Respiratory Equipment
Humidifiers (E0550, E0555, E0560) are covered for members when medically necessary for humidification during PAP treatments or for treatment of respiratory conditions.
Vaporizers (E0605) and postural drainage boards (E0606) are covered when medically necessary for treatment of respiratory conditions. MHCP covers room-size type vaporizers described by HCPCS code E0605.
Closed system tracheal suction catheters (A4605) are covered for ventilator dependent members with tracheostomies and require closed suctioning to prevent hypoxemia.
Peak expiratory flow rate meters (A4614) are covered for members with asthma or similar conditions and require regular monitoring of peak expiratory flow.
Breathing circuits (A4618) are covered for members who use ventilation or anesthesia and require an interface for the equipment. Breathing circuits are included in payment for ventilator rentals.
Face tents (A4619) are covered for members who receive oxygen and cannot tolerate masks or cannulas.
Variable concentration masks (A4620) are covered for members who do not require a fixed concentration of oxygen.
Ventilators Table
Payment for certain respiratory equipment is included in payment for dual-function ventilators (E0468) and multifunction ventilators (E0467). Payment for HCPCS codes listed in column 2 of the Ventilators Table are included in payment for any of those listed in the same row as column 1:
Ventilators Table
Column 1 | Column 2 |
E0468 | A4618, E0465, E0466, E0482, E0470, E0471, E0472, E0486, E0601 |
E0467 | A4618, E0465, E0466, E0482, E0483, E0484, E0470, E0471, E0472, E0486, E0565, E0570, E0572, E0585, E0600, E0601 |
Respiratory Equipment Supply Codes Table
The HCPCS codes listed in the Respiratory Equipment Supply Codes Table are covered as supplies for medically necessary respiratory equipment:
Respiratory Equipment Supply Codes Table
A4604 | A4616 | A7027 | A7031 | A7035 | A7039 |
A4605 | A4617 | A7028 | A7032 | A7036 | A7044 |
A4614 | A4619 | A7029 | A7033 | A7037 | A7045 |
A4615 | A4620 | A7030 | A7034 | A7038 | A7046 |
Refer to the Medical Supply Coverage Guide (PDF) for coverage information and quantity limits on equipment and supplies.
Noncovered Services
MHCP does not cover the following:
Refer to information under the Noncovered Services heading in the Billing the Member (Recipient) section of the MHCP Provider Manual to review the conditions required to bill the member.
Authorization
Authorization is required for the following:
Submit authorization requests and required documentation to the Medical Review Agent. The medical review agent will not approve requests when due to willful or careless destruction by a member, unless documentation shows that the destruction was because of the physical or mental impairment of the member.
Documentation must show a failed CPAP trial or medical contraindication to a CPAP device for rentals of BiPAPs without backup rate for indications other than obstructive sleep apnea.
Documentation for authorization requests for second ventilators must include:
Refer to the Equipment and Supplies section of the MHCP Provider Manual for other authorization requirements.
Billing
Providers are responsible to coordinate services. Refer to the Billing Policy Overview section of Provider Basics section of the MHCP Provider Manual for general billing information.
Bill respiratory equipment using MN–ITS 837P. Refer to the MHCP MN–ITS user guide Billing for Durable Medical Equipment, Medical Supplies, Prosthetics and Orthotics, and Augmentative Devices for claim instructions.
Ventilators are rental items only.
BiPAPs and CPAPs are capped rental items only, unless with an approved authorization for third party liability (TPL) that requires purchase rather than rental.
Supplies for respiratory equipment are purchase items only.
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