Respiratory Equipment

Revised: May 8, 2024

· Overview

· Eligible Providers

· 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 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 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.

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

· Have 24-hour-a-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 member is not directly observed by a fully trained caregiver

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

TPL and Medicare

Review the Equipment and Supplies section of the Minnesota Health Care Programs Provider Manual for information on TPL and Medicare.

Eligible Members

Respiratory equipment and related supplies are covered for eligible MHCP 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 (OSA) section of the MHCP Provider Manual for members with OSA.

Covered Services

The following services are covered:

· Codes: E0465, E0466, E0467, E0470-E0472, E0601, A4604, A7027-A7039, A7044-A7046

· Rental of BiPAP device for members with medical conditions that require ventilation assistance if the member has spontaneous respiration

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

· Rental of BiPAP device with backup rate for members with obstructive sleep apnea and co-existing breathing disorders. Both diagnosis codes must be on the claim

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

· Refer to the Positive Airway Pressure for Treatment of Obstructive Sleep Apnea (OSA) section of the MHCP Provider Manual for policy about CPAP and BiPAP use for sleep apnea.

· Rental of a ventilator for members 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 member’s needs. The second ventilator requires authorization. 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 (with documentation that both modalities cannot be served by a multi-function 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 as well as the same type of device for use while in bed AND without both pieces of equipment, the individual may be prone to medical complications, may be unable to achieve appropriate medical outcomes, or may not be able to use the medical equipment effectively.

· 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. 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 E0467 are not separately reimbursable unless the client has oxygen needs over 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.

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

· All breathing circuits

· Carrying case

· Cart

· Electric cord

· Exhaustion valves

· High, low and disconnect alarms

· High-pressure hoses

· IMV devices

· PEEP valve

· Pressure manometers

· Spirometer, any kind

· Stand

· Water traps

Separately billable from ventilator rental:

· Humidifier

· Manual resuscitation bags

· Oxygen

· Oxygen analyzers

Noncovered Services

Back-up ventilators (manual resuscitation bags are covered), back-up CPAP devices and back-up BiPAP devices are not covered as they are a duplication of equipment.

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

Submit authorization requests and required documentation to the authorization medical review agent.

The following require authorization:

· All purchases of CPAP or BiPAP devices. Documentation must show that the primary payer requires purchase rather than rental of the device.

· Rental of a CPAP device for indications other than obstructive sleep apnea. Documentation must show that respiratory equipment is medically necessary, and that the member does not require a BiPAP device or ventilator.

· 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 member unless documentation shows that the destruction was because of the physical or mental impairment of the member.

· Authorization is required for a second ventilator. Authorization requests must include a letter of medical necessity that addresses all the following criteria as applicable:

· Member-specific medical necessity. General statements of medical necessity that are not member specific will not be accepted.

· Explanation of the member’s daily activities and ventilator needs during those activities. (Include transfer and mobility needs and caregiver assistance required.)

· Include an explanation of the member’s activities outside of the home including school, work or other settings regularly frequented and any specific ventilator needs for travel.

· Include all pertinent diagnoses and ventilator settings (for example, dual settings or duration)

· Include any respiratory treatments or devices used and duration. Examples: suction, oxygen, or other respiratory treatments.

· Explain the two different ventilators, what they are doing for the member and why they are both required.

· Submit the most recent physician and or pulmonologist progress note.

· Submit documentation that you have addressed 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.

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

· Have 24-hour-a-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 member is not directly observed by a fully trained caregiver

· 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.

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 member, billing must be based on the member’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.

· When dispensing a medically necessary pressure support ventilator, bill using modifiers RR and U3. 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.

· 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.