Respiratory Equipment

Revised: March 12, 2026

· Overview

· Eligible Providers

· TPL and Medicare

· Eligible Members

· Covered Services

· Noncovered Services

· Authorization

· Billing

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:

· Federally qualified health centers

· Home health agencies

· Indian Health Services

· Medical suppliers

· Pharmacies (CPAP and BiPAP equipment only)

· Rural health clinics

Because ventilators are life-sustaining equipment, providers must:

· Conduct an in-home environmental assessment to confirm the member’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; and

· Train the member and caregivers in proper use of the ventilator, including infection control, alternative ventilation, and emergency ventilation procedures; and

· Have 24-hour-a-day support for troubleshooting and ventilator exchange due to unresolved malfunction; and

· Ensure critical alarms are appropriately set on the ventilator; and

· Ensure a backup alarm system is in place for when the member is not directly observed by a fully trained caregiver; and

· Perform periodic maintenance at least as frequently as recommended by the manufacturer.

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, E0600, E0601

MHCP covers the following equipment:

· Home ventilators with invasive interface (E0465)

· Home ventilators with noninvasive interface (E0466)

· Multifunction respiratory ventilators (E0467)

· Dual-function respiratory ventilators (E0468)

· BiPAP devices without backup rate with noninvasive interface (E0470)

· BiPAP devices with backup rate with noninvasive interface (E0471)

· BiPAP devices with backup rate with invasive interface (E0472)

· Electric respiratory suction pumps (E0600)

· CPAP devices (E0601)

· Supplies and replacement parts, including:

· Replacement parts (A7028, A7029, A7031 to A7033, A7045 to A7046)

· Full face masks (A7030), nasal interfaces and cannulas (A7034, A4615), oral interfaces (A7044, A7047), mouthpieces (A4617), face tents (A4619), variable concentration masks (A4620), and combination oral and nasal masks (A7027)

· Disposable (A7038) and nondisposable (A7039) filters

· Headgear (A7035) and chinstraps (A7036)

· Tubing (A7037, A4616) and tubing with integrated heating elements (A4604)

· Tracheal suction catheters (A4605)

· Peak expiratory flow rate meters (A4614)

· Breathing circuits (A4618)

MHCP covers the following services:

· Rental of BiPAP device (E0470) for members with medical conditions that require ventilation assistance if the member has spontaneous respiration. Diagnosis must be on the claim.

· Rental of BiPAP device with backup rate (E0471, E0472) for members with obstructive sleep apnea and coexisting breathing disorders. Diagnoses must be on the claim.

· Rental of CPAP device (E0601) for members with breathing disorders other than obstructive sleep apnea with authorization.

· Purchase of CPAP or BiPAP device with authorization if the member has a third party insurance that requires purchase rather than rental.

· Rental of a ventilator (E0465, E0466) for members who have been determined by a physician to need a ventilator.

· Purchase or rental of a respiratory suction pump (E0600) for members who require upper respiratory oral pharyngeal and tracheal suction to remove mucus and other secretions from the airway. 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 unless substantial documentation establishes that a portable pump alone does not meet the member’s needs.

· Rental of a portable and a stationary ventilator with authorization if substantial documentation establishes that a portable ventilator alone does not meet the member’s needs. Examples of this could include the following:

· The member requires the use of one type of respiratory device during a portion of the day and the use of a second device during another portion of the day and documentation shows that both modalities cannot be served by a multifunction respiratory device.

· The member is wheelchair bound and requires a respiratory assist device to be mounted to the wheelchair for use when out of the bed and the same type of device for use while in bed, and without both pieces of equipment, the individual may be prone to medical complications or unable to achieve appropriate medical outcomes or use the medical equipment effectively.

· Rental of the dual-function ventilator (E0468) is covered for members who would otherwise require both a ventilator and a cough-stimulating device (E0482). HCPCS code E0468 must be billed without another ventilator rental. The dual-function ventilator has the capability of completing the cough stimulation function. All 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.

· Rental of the multifunction ventilator (E0467) is covered for members who would otherwise require both a portable and a stationary ventilator but can be served by the multifunction ventilator alone. HCPCS code E0467 must be billed without another ventilator rental. Additionally, the multifunction ventilator also has the capability of completing the nebulizer, oxygen, cough assist, and suction functions. All 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.

Payment for the following HCPCS codes is included in the payment for the dual-function ventilator (E0468):

E0468

E0465, E0466, E0482, E0470, E0471, E0472, E0486, E0601

Payment for the following HCPCS codes is included in the payment for the multifunction ventilator (E0467):

E0467

E0465, E0466, E0482, E0483, E0484, E0470, E0471, E0472, E0486, E0565, E0570, E0572, E0585, E0600, E0601

Included with initial CPAP or BiPAP dispensing:

· Carrying case

· Compressor

· CPAP valve (if separate from mask)

· Disconnection alarm (if needed)

· Filters

· Fuses

· Instruction manual

· Power cord

· Permanent circuits

· Swivel adapters

· Manometer

Separately billable at initial CPAP or BiPAP dispensing:

· Head gear

· Mask

· Tubing

· Humidification device

Included with ventilator rental:

· Battery

· Battery chargers

· Battery cables

· Breathing circuits

· Carrying case

· Cart

· Electric cords

· Exhaustion valves

· High, low and disconnect alarms

· High-pressure hoses

· IMV devices

· PEEP valves

· Pressure manometers

· Spirometers

· Stands

· Water traps

Separately billable from ventilator rental:

· Humidifiers

· Manual resuscitation bags

· Oxygen

· Oxygen analyzers

Respiratory Equipment Supply Codes
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 limits on supplies.

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.

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.

Noncovered Services

MHCP does not cover the following:

· Backup devices, other than two ventilators with authorization, as they are a duplication of equipment

· The following supplies for ventilators, as ventilator rentals do not convert to purchase, and therefore supplies are included in payment for the service:

· Batteries (A4611)

· Cables (A4612)

· Chargers (A4613)

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:

· Quantities over MHCP quantity limits

· All purchases of CPAP or BiPAP devices when the primary payer requires purchase rather than rental of the device

· Rentals of CPAP devices for indications other than obstructive sleep apnea when the equipment is medically necessary and the member does not require a BiPAP device or ventilator

· Rentals of BiPAP devices for treatment of obstructive sleep apnea

· Second ventilators

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 for indications other than obstructive sleep apnea.

Documentation for authorization requests for second ventilators must include:

· Order

· Letter of medical necessity that address all of the following criteria:

· Member-specific medical necessity (general statements are not acceptable)

· Member’s diagnoses and pertinent ventilator settings (for example, dual settings or duration)

· Clinical history, including most recent progress note and prior treatments or devices used and duration (for example, suction, oxygen, other respiratory treatments)

· Explanation of the member’s activities of daily living (ADLs) both inside and outside the home and ventilator needs during ADLs

· Explanation of the member’s transfer and mobility needs, caregiver assistance required, and any specific ventilator needs for travel

· Explain the two different ventilators, including functions, and why they are both medically necessary

· Documentation of the following safety concerns about the second ventilator with the member or caregivers:

· Conduct an in-home environmental assessment to confirm the member’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; and

· Train the member and caregivers in proper use of the ventilator, including infection control, alternative ventilation and emergency ventilation procedures; and

· Have 24-hour-a-day support for troubleshooting and ventilator exchange due to unresolved malfunction; and

· Ensure critical alarms are appropriately set on the ventilator; and

· Ensure a backup alarm system is in place for when the member is not directly observed by a fully trained caregiver; and

· Perform periodic maintenance at least as frequently as recommended by the manufacturer.

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.

· Use modifier NU for purchases.

· Use modifier RR for rentals.

· Use modifiers KH, KI, KJ, and RR as appropriate for capped rentals.

· Billing must be based on the member’s medical condition when dispensing a device that can provide multiple levels of treatment (a device with CPAP, BiPAP or ventilator modes) to a member. Providers must have documentation from the prescriber that is sufficient to support the level of service for which the supplier is billing.

· Bill using modifiers RR and U3 when dispensing a medically necessary pressure support ventilator. Providers must have documentation from the prescriber that establishes the need for pressure support. When dispensing other accessories or devices which have been coded by the PDAC, providers must bill with the assigned procedure code and accept the MHCP fee schedule rate.

· Ventilators have been determined by the Centers for Medicare & Medicaid Services to require frequent and substantial servicing. MHCP will not purchase ventilators, and rented ventilators do not convert to purchase.

· Use modifier 76 when requesting prior authorization for a second ventilator. Modifier 76 must also appear on the prior authorization when billing using modifier 76 or the claim will be denied.

· CPAP and BiPAP equipment are capped rental only unless a primary payer requires purchase and authorization is obtained.

· Bill the first three months of CPAP or BiPAP equipment using modifier RR and modifiers KH, KI or as appropriate.

· When billing for rental of CPAP or BiPAP equipment after the first three months, use modifiers RR and KJ as appropriate and modifier KX if documentation in the file supports that the supplier has verified member compliance with treatment. Do not use modifier KX if the supplier has not verified compliance, or if the supplier has information that the member is not compliant with treatment except as described above.

· CPAP and BiPAP equipment are expected to serve the member for at least five years. If a device is stolen or damaged beyond repair, a replacement device may be covered with authorization.

Ventilators are rental only items.

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-only items.