Home Mechanical Ventilation: Coding and Reimbursement Explained by Canadian Health&Care Mall

March 15, 2016 Category: Mechanical Ventilation

Ventilator-Assisted Individuals patientAlthough the home has been noted to be one of the lowest cost points of care for VAIs, the lack of published information and recognized standards of care leaves notable gaps in the coding and coverage methodologies. An addition to the current procedure terminology (or CPT) coding may provide some relief in tracking VAI patient services. The new current procedure terminology code 94005 (“Home Ventilator Management Care Plan Oversight”) can be used by physicians who are managing HMV patients.

The majority of coding and payments fall into the area of HME. HME is identified and billed using level II HCPCS codes and is reimbursed under the Medicare part B benefit (for Medicare beneficiaries) or the durable medical equipment benefit under Medicaid and/or private health plans. Home mechanical ventilators are identified by a series of four unique codes with a maximum payment allowable for each code. Medicare currently pays an average of approximately $950 per month as a global fee for invasive HMV. The maximum payment allowable for each state Medicaid and private insurance payor varies greatly, with an estimated range of $600 to $1,500 per month. Under Medicare part B, Medicare pays 80% of the allowed amount, leaving the 20% copay balance as the responsibility of the beneficiary. Most Medicaid programs do not have any copay or deductible for medical equipment; however, the copay and deductibles for medical equipment within the private insurance plans vary greatly, with the most extreme being no HME coverage. Table 1 outlines the most current HCPCS codes and descriptions.

The HMV Technology

In the 1980s, we saw the introduction of what most clinicians consider to be the modern portable or home mechanical ventilators. Most portable ventilators were relatively small and lightweight (compared to hospital equipment) and typically were housed in cast aluminum frames. Nearly all of the first-generation portable home ventilators used some type of simple bellows or piston design to generate the needed flow, pressure, and volume. Although considered somewhat basic and low technology by critical care standards, the first-generation portable ventilation devices were clinically effective and very reliable; opening the doors to home for many ventilator-dependent individuals and their families. Majority of such people make orders of drugs via Canadian Health&Care Mall healthcaremall4you.

The expanding use of invasive HMV in infants and pediatric patients has changed the home-care clinical landscape for both HME providers and the ventila tor manufacturers. In contrast to the more basic provisioning of adult patients with long-term basic ventilation (ie, assist-control and no positive end-expiratory pressure), infants and pediatric patients often have more demanding and complex ventilation and airway management needs, with more critical care processes, such as weaning and tracheostomy tube decannulation, frequently incorporated into the care plan. As a result, the portable home ventilator technical capabilities have expanded to accommodate the complex clinical and lifestyle needs of this new and growing population of home VAIs. Modern portable ventilators now include advanced modes of ventilation with a variety of unique features and benefits.

Table 1——Description of HCPCS Codes

HCPCS Codes Description
E0450 Volume control ventilator without pressure support (may include pressure control); used in conjunction with an invasive interface (ie, tracheostomy)
E0461 Volume control ventilator without pressure support (may include pressure control); used in conjunction with noninvasive interface
E0463 Pressure-support ventilator with volume control; may include pressure control; used with invasive interface (ie, tracheostomy)
E0464 Pressure-support ventilator with volume control; may include pressure control; used with noninvasive interface

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