Respiratory Assist Devices

Coverage

Documentation

Reviews/Audits

  • Medical Review - View notifications/findings of pre/post claim reviews completed by Noridian Medical Review

Tips

Topic Details
Multi-function ventilator (HCPCS code E0467)
  • 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.
RAD vs. PAP Compliance
  • 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.
Diagnosis Categories

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.

Replacement
  • 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.
Ventilators

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.

 

Last Updated Feb 19 , 2024

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