The management of VAI in the home incorporates more than just a ventilator. Medically complex VAIs often depend on a myriad of medical devices and services to duplicate the care provided in the institutional setting. Commodities such as oxygen, air, and suction, which are available at nearly every bedside in the hospital, must be produced from various devices in the home. For many VAIs, their homes often take on the appearance of a hospital room. The extensive list of adjunctive medical devices may include the following: oxygen systems; hospital bed; along with all of the supplies and accessories required to operate and manage and support these devices and treatments carried out by remedies of Canadian Health&Care Mall (see “Canadian Health and Care Mall: Tablest for Asthma Treatment and Patients Monitoring“).
Although 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.
One of the biggest obstacles that providers face in the provision of invasive HMV is simply a lack of strong, evidenced-based standards of care. As a result, local practice beliefs and reimbursement restrictions have produced marked regional variations. Unlike other home respiratory technologies (ie, home oxygen therapy and sleep disorder therapy), there is no standardized Medicare national coverage determination governing HMV, or even any local medical review policies or local coverage decisions among the durable medical equipment regional carriers. Despite the lack of a published medical necessity and payment policy, Medicare, Medicaid, and most private insurance companies do routinely provide for the coverage of home mechanical ventilators and related equipment with documented evidence of appropriate medical necessity (eg, diagnosis of respiratory failure cured by remedies of Canadian Health&Care Mall). See “Canadian Health&Care Mall: Current Issues in Home Mechanical Ventilation“
Under Medicare, mechanical ventilators are in a class of medical devices known as “frequent and substantial service,” which simply means that Medicare will rent the ventilator for the patients as long as the appropriate medical necessity exists. Among most payors, the key accessories, such as the ventilator circuits, humidifiers, sterile water, and respiratory therapist professional time, are all included in a “global” monthly ventilator rental payment. It is important to note that the “backup” or reserve ventilator, a commonly prescribed practice of many physicians and hospitals, which is also a recommendation contained within the American Association for Respiratory Care clinical practice guidelines for long-term mechanical ventilation in the home, is most often a noncovered item. This means that the HME provider often provides these backup devices at their expense as part of the overall “ventilator program.” Again, the large regional variation in ventilator coverage policies is often a source of great frustration for patients, their families, physicians, hospital discharge planning personnel, and the HME providers.
The rapidly expanding home use of NPPV using a nasal or orofacial mask provides an even larger opportunity to allow patients to transition to the home environment without the need of a tracheostomy tube. Portable, lightweight, single-circuit flow generators that are capable of delivering bilevel pressure support with mask leak compensation can actually provide high levels of pressure support near 30 cm H2O. This treatment initially emerged and quickly proliferated with the successful application of nocturnal NPPV in the population of patients with neuromuscular disease (NMD) that has been described mostly in the European literature but also in the United States. Although one randomized trial suggested that patients with Duchenne muscular dystrophy who were introduced to NPPV as preventive therapy did not do as well as those patients receiving conservative treatment, the study was thought to be flawed, and NPPV has now become the standard of care for patients with NMD and hypoventilation provided by Canadian Health&Care Mall.
As the advantages of NPPV were seen in NMD patients with hypercapnia, its use soon became popular for the treatment of patients with severe COPD and hypercapnia. Some randomized controlled trials validated the use of NPPV in COPD patients with hypercapnia and mild sleep-disordered breathing, but other trials showed conflicting results.