CMS overhauls vent product category

WASHINGTON - CMS announced on Thursday that it has dropped non-invasive vents from the competitive bidding program for Round 1 2017.

The decision is part of a complete overhaul of the product category, with the agency also announcing that it would create two new codes for vents on Jan. 1 (one for non-invasive and one for invasive), and discontinue five existing codes (E0450, E0460, E0461, E0463, E0464).

“For Medicare program purposes, this change is needed to correctly apply national coverage rules and statutorily mandated payments rules for vents, and to prevent abuse of the program,” the agency stated.

The move is response to what CMS calls a “dramatic increase in utilization and expenditures for E0463 and E0464.” Allowed charges for E0463 were about $63 million in 2014 vs. about $48 million in 2012. Allowed charges for E0464 were about $181 million in 2014 vs. about $35 million in 2012.

What's behind that increase? CMS believes E0464 is too frequently used to bill for pressure support vents that can also function as and are used as positive airway pressure devices for the treatment of obstructive sleep apnea rather than respiratory failure.

“In these instances, the devices are paid using the wrong fee schedule amounts and payment rules,” the agency stated.

CMS has made a number of moves to distinguish vents from CPAP and BiPAP devices. In May, it announced it was revising its 855S enrollment application to make vents a separate category. It has also put non-invasive vents under widespread prepayment review.

In explaining the code changes, CMS stated: “Since the Medicare coverage rules for ventilators are the same regardless of what type of ventilator is being used, there is no program need to have codes for different types of ventilators. Therefore, codes E0450, E0460, E0461, E0463, and E0464 will be discontinued effective Dec. 31, 2015. New code Exxx1 will be used for ventilators currently described by codes E0450 and E0463, while new code Exxx2 will be used for ventilators currently described by codes E0460, E0461 and E0464.”

CMS stated it will use the Medicare fee schedule amounts for E0450 to establish the fee schedule amounts for both new codes, thereby restoring payment to the levels mandated by the statute for ventilators in general.

The agency stated it intends to closely monitor use of the new codes to ensure that items used for the treatment of OSA are not being billed under these new codes.

CMS is accepting comments until June 25. Send comments to CodingComments@cms.hhs.gov and include “Ventilator Comments” in the subject line.