Vents: Providers should be on alert

HINGHAM, Mass. - Industry stakeholders worry what a recently announced widespread prepayment review for non-invasive ventilators in Jurisdiction A may mean for coverage and reimbursement going forward.

The NHIC, the DME MAC for that jurisdiction, says it has initiated the review due to a spike in billing for E0464, a product that costs Medicare about $1,500 a month on a rental basis.

“We knew it was only a matter of time,” said Wayne van Halem, president of the van Halem Group. “The volume for this code has increased dramatically.”

Why the spike? The popularity of non-invasive vents (they've had “amazing results,” van Halem says); an increase in the use of non-invasive vents over Bi-Level devices; and the lack of specific coverage criteria.

While the National Coverage Determination (NCD) outlines general criteria for the provision of vents, there are no Local Coverage Determinations (LCDs) with specific criteria, stakeholders say.

“It has given providers a false sense of security—there's no coverage criteria, so it can't be audited,” van Halem said. “That's just not the case.”

What could happen next: The other jurisdictions could follow suit, and depending on what they all find, a new policy with more specific coverage criteria and a modified payment methodology could be implemented.

“Providers will want to be very proactive that their documentation not only supports the clinical need but also that Bi-Level was tried and ruled out,” van Halem said.

When it comes to providing non-invasive vents vs. Bi-Level devices, the DME MACs began laying out their case in a bulletin in April. After stating the conditions for which vents are covered, they stated: “Each of these disease categories are comprised of conditions that can vary from severe and life-threatening to less serious forms. These disease groups may appear to overlap conditions described in the Respiratory Assist Devices LCD, but they are not overlapping. Choice of an appropriate device i.e., a ventilator vs. a bi-level PAP device is made based upon the severity of the condition.”

Brian Simonds, a provider in Jurisdiction A, isn't opposed to more specific coverage criteria for non-invasive vents—in Massachusetts, where he's located, the Medicaid program requires prior authorizations—but he says any attempt to, say, cap reimbursement is unacceptable.

“We're taking a huge risk in getting these patients home,” said Simonds, director of Baystate Home Infusion & Respiratory Services. “There's a tremendous amount of education for the patient and the family. Then there are the preventative maintenance requirements. It's not just like regular equipment. You have to be very vigilant.”