Respiratory Assist Devices - JD DME

Ventilators may be covered for these conditions:

• Neuromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure, consequent to chronic obstructive pulmonary disease. This includes both positive and negative pressure types. Thorough medical records can help determine coverage for a ventilator.

• If the beneficiary is using a multi-function ventilator (HCPCS code E0467) but not using or have all four functions available (functions are oxygen concentrator, nebulizer, aspirator; and cough stimulator), suppliers must bill E1399. If the supplier is billing with HCPCS code E1399 then the supplier must enter a description of which function of the device is being used by adding that to the narrative of the claim being billed along with the following:
  • Manufacturer name
  • Product name and number
  • Supplier Price List (PL) amount
  • HCPCS code of related item (if applicable)
• Include the narrative information in loop 2400 (line note), segment NTE02 (NTE01=ADD) of the ANSI X12N, version 5010A1 professional electronic claim format or on Item 19 of the paper claim form in the narrative field.
• Miscellaneous HCPCS codes billed without this information will be rejected and will need to be resubmitted with the missing information included.

• Claims with Date of Service on or after April 1, 2024, HCPCS code E0468 is eligible for Medicare Billing
• Home ventilator, Dual-Function respiratory device, also performs additional function: cough stimulation

Included in functionality of or considered same/similar to E0468

• Ventilators (HCPCS codes E0465, E0466)
• Cough Stimulators:
• Mechanical In-Exsufflation devices and related accessories (HCPCS codes E0482 and A7020)
• PAP devices, respiratory assist devices (RADs), and related accessories (HCPCS codes E0470, E0471, E0472, E0601, A4604, A7027, A7028, A7029, A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7044, A7045, A7046, E0561, E0562)
• Oral Appliances (HCPCS code E0486)

• Ventilators (HCPCS codes E0465, E0466)
• Oxygen and oxygen equipment (HCPCS codes E0424, E0431, E0433, E0434, E0439, E0441, E0442, E0443, E0444, E0447, E1390, E1391, E1392, E1405, E1406, and K0738)
• Nebulizers and related accessories (HCPCS codes E0565, E0570, E0572, E0585, A4619, A7003, A7004, A7005, A7006, A7007, A7012, A7013, A7014, A7015, A7017, A7525, and E1372)
• Aspirator and related accessories (HCPCS codes E0600, A4216, A4217, A4605, A4624, A4628, A7000, A7001, A7002, and A7047)
• Cough Stimulators and related accessories:
• Mechanical In-Exsufflation devices and related accessories (HCPCS codes E0482 and A7020)
• High Frequency Chest Wall Oscillation Devices (HFCWO) and related accessories (HCPCS codes E0483, A7025, A7026)
• Oscillatory positive expiratory pressure device (e.g., Flutter, Acapella and similar items) (HCPCS Code E0484)
• PAP devices, respiratory assist devices (RADs), and related accessories (HCPCS codes E0470, E0471, E0472, E0601, A4604, A7027, A7028, A7029, A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7044, A7045, A7046, E0561, E0562)
• Oral Appliances (HCPCS code E0486)

• RAD - To reach compliance in the beneficiary’s 90-day window, the beneficiary needs to be consistently using and benefiting from a RAD device for greater than or equal to 4 hours in a 24-hour window. This criteria is different from the PAP policy for obstructive sleep apnea (OSA).The phrase consistently is determined ONLY by the treating practitioner.
• For both PAP and RAD you cannot bill for the 4th month until the beneficiary has reached compliance. PAP and RAD use the same supplies and the utilization criteria is the same.

A RAD (E0470, E0471) is covered for those beneficiaries with one of the following clinical disorders:

• Restrictive thoracic disorders (i.e., neuromuscular diseases or severe thoracic cage abnormalities)
• Severe chronic obstructive pulmonary disease (COPD)
• CSA or CompSA,
• Hypoventilation syndrome

RAD is a diagnosis driven policy each with their own coverage criteria requirements outlined in the LCD.

• If an E0470 or E0471 device is replaced during the 5-year reasonable useful lifetime (RUL) because of loss, theft, or irreparable damage due to a specific incident, there is no requirement for a new clinical evaluation or testing.
• If an E0470 or E0471 device is replaced following the 5-year RUL, there must be an in-person evaluation by their treating practitioner that documents that the beneficiary continues to use and benefit from the device. There is no requirement for new testing. A new order is required.