CMS loosens requirements for respiratory equipment

WASHINGTON - CMS in an interim final rule published March 30 appeared to significantly expand access to respiratory therapy by temporarily waiving the coverage criteria and face-to-face requirements during the coronavirus pandemic.

The agency says NCDs and LCDs that point to clinical indications for coverage for respiratory equipment— including but not limited to home oxygen, CPAPs, RADs, ventilators and infusion pumps—as well as to face-to-face evaluations, will not apply during the public health emergency.

“As much as possible, if the physician says something is necessary, as a DME supplier, you're allowed to provide it,” said Kelly Grahovac, general manager at The van Halem Group, a division of VGM Group.

The changes are effective immediately and apply retroactively to March 1.

Despite the new flexibility, Grahovac advises providers to still document need as best as they can by citing regulatory changes from CMS and taking other steps.

“If you have documentation, great,” she said. “If you don't, at a minimum, you want to document why you don't have it. Even a little note that says, 'It happened during this time and we were unable to get it,' helps to provide a narrative. That way you have something to back up why you don't have it.”

While COVID-19 is a respiratory virus, stakeholders are now making the case to CMS that the changes should also apply more broadly to HME.

“If you can't get a clinical note or a face-to-face evaluation, that could be about a wheelchair or hospital bed order,” said Kim Brummett, vice president of regulatory affairs for AAHomecare. “We've gone back to them and said this is great but the challenges are not limited to respiratory equipment.”

But not all stakeholders interpret CMS's IFR as waiving the face-to-face requirement outright, believing instead that it expands a physician's toolbox for meeting that requirement with alternative methods like telehealth.

“In my experience and in my reading of the tone of the IFR, I don't expect Medicare to say we don't need, for example, an oxygen saturation test,” said Andrea Stark, a reimbursement consultant for MiraVista. “They want these patients monitored more, not less, and are opening the door to telehealth as a way to do that more safely. Telehealth is the new virtual face to face.”

Before Stark could “make the leap” that a doctor's order without objective evidence will suffice, she'd need to see something in writing from the DME MAC medical directors that states that explicitly.

“The guidance in the IFR is not explicit,” she said. “It doesn't go as far as to say an order is all you need.”