RETIRED - Correct Coding, Billing and Code Verification of HCPCS Code E0467 (Multi-Functional Ventilator) - JA DME

Joint DME MAC and PDAC Article
Posted on November 11, 2021

Code E0467 (HOME VENTILATOR, MULTI-FUNCTION RESPIRATORY DEVICE, ALSO PERFORMS ANY OR ALL OF THE ADDITIONAL FUNCTIONS OF OXYGEN CONCENTRATION, DRUG NEBULIZATION, ASPIRATION, AND COUGH STIMULATION, INCLUDES ALL ACCESSORIES, COMPONENTS AND SUPPLIES FOR ALL FUNCTIONS) describes a device that is a home ventilator and incorporates all of the following four (4) additional functions:

1. Oxygen concentrator;
2. Nebulizer;
3. Aspirator; and,
4. Cough stimulator

The fee schedule for code E0467 was established according to regulations at 42 CFR 414.222(f)(2) and (f)(3); consequently, billing a device coded E0467 must incorporate a home ventilator plus all 4 additional functions listed above.

If the device is a multifunctional ventilator but does not have all four functions as listed above, suppliers must bill:

E1399 (DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS)

For billing of code E1399, the supplier must enter a description of the item which includes all functions of the device, manufacturer name, product name/number, supplier price list, and HCPCS of related item in loop 2300 (claim note) and/or 2400 (line note), segment NTE02 (NTE01=ADD) of the ANSI X12N, version 5010A1 professional electronic claim format or in Item 19 of the paper claim form.

Effective for claims with dates of service on or after January 1, 2022, the only products that may be billed using Healthcare Common Procedure Coding System (HCPCS) codes E0467, are those that have received mandatory code verification review and are listed on the Product Classification List (PCL) of the Pricing, Data Analysis, and Coding (PDAC) contractor website. Manufacturers with products in this category of items must submit their products for coding verification review by December 31, 2021.

Additionally, please note that the functions of the E0467 incorporate features that would render billing of positive airway pressure (PAP) devices, respiratory assist devices (RAD), and custom fabricated oral appliances as same or similar.

Correct coding is an essential element for correct claim payment. The Pricing, Data Analysis and Coding (PDAC) contractor maintains a variety of resources to assist suppliers in determining the appropriate code for Medicare billing. For questions about correct coding, contact the PDAC HCPCS Helpline at (877) 735-1326 during the hours of 9:30 am to 5:00 pm ET, Monday through Friday. You may also visit the PDAC website to chat with a representative, or select the Contact Us website button at the top of the PDAC website for email, FAX, or postal mail information.

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