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Reimbursement for Portable Ventilators
"Quick Guide" to Coding, Coverage and Payment
of Portable Ventilators
To view our Quick Guide for Coding, Coverage and Payment **,
please click here.
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Check back regularly for updates.
DMEPOS Coverage Policy
The Medicare Program covers ventilators under the durable medical equipment benefit
"for treatment of neuromuscular diseases, thoracic restrictive diseases and chronic
respiratory failure due to chronic obstructive pulmonary disease." This coverage includes
both positive and negative pressure types.
(Source: DMEPOS Coverage Issues Manual, Section 60-9)
Ventilator Accessories
Under the Medicare Program, coverage and payment for ventilator accessories (circuits,
filters, batteries and humidifiers) is included in coverage and payment for the ventilator
(frequent and substantial servicing payment category).
Some non-Medicare payers may cover and pay separately for ventilator accessories under
prescribed conditions, such as if the ventilator is purchased for the patient.
Coverage for Second Ventilators
While there is no national Medicare guideline on coverage for second ventilators, the
Durable Medical Equipment Regional Carriers (DMERCs) have published instructions
regarding coverage of "backup equipment," which state that a backup ventilator of the
same or similar type provided at the bedside as a precaution in case of malfunction of the
primary ventilator will not be covered. These publications further specify:
"Backup equipment must be distinguished from multiple medically necessary items
which are defined as identical or similar devices, each of which meets a different medical
need for the patient. Though Medicare does not pay separately for backup equipment,
Medicare may make separate payment for a second piece of equipment if it is required to
serve a different purpose as determined by the patient's medical needs. Examples of
situations in which multiple equipment may be covered include:
- A patient requires one type of ventilator (e.g. a
negative pressure ventilator with a chest shell) for part of the day and needs
a different type of ventilator (e.g. a positive pressure ventilator with a
nasal mask) during the rest of the day.
- A patient who is confined to a wheelchair requires a ventilator mounted on the
wheelchair for use during the day and needs another ventilator of the same
type for use while in bed. Without both pieces of equipment the patient may
be prone to certain medical complications, may not be able to achieve certain
appropriate medical outcomes, or may not be able to use the medical
equipment effectively.
(Sources: DMERC Region A - Supplier Notice 99-06; DMERC Region B Supplier Bulletin 97-03; DMERC Region C -
1997 DMERC Medicare Advisory; DMERC Region D - December 1997 DMERC Dialogue)
HCPCS Coding and Medicare Payment Guidelines
For payment information, click on code.
| HCPCS Code* | Description |
|
E0450
| Volume control ventilator, without pressure support mode, may include pressure control mode, used with invasive interface. |
|
E0461
| Volume control ventilator, without pressure support mode, may include pressure control mode, used with noninvasive interface. |
|
E0463
| Pressure support ventilator with volume control mode, may include pressure control mode, used with invasive interface. |
|
E0464
| Pressure support ventilator with volume control mode, may include pressure control mode, used with noninvasive interface. |
* Existence of coding does not guarantee coverage or payment for any procedure by any payer. Medical necessity
for the procedure must be established by the patient's physician in accordance with specific payer guidelines.
Medicare Durable Medical Equipment Regional Carrier (DMERC) Payer Links
- Region A (HealthNow NY, Inc): CT, DE, MA, ME, NH, NJ, NY, PA, RI, VT
- Region B (AdminaStar Federal Medicare): DC, IL, IN, MD, MI, MN, OH, VA, WV, WI
- Region C (Palmetto Government Benefits Administrator): AR, CO, FL, GA, KY, LA, MS, NC, NM, OK, SC, TN, TX
- Region D (CIGNA Government Services): AL, AZ, CA, HI, ID, IA, KS, MO, MT, ND, NE, NV, OR, SD, UT, WA, WY
**
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CPT Only® 2004 American Medical Association All Rights Reserved.
Existence of coding does not guarantee coverage or payment for any procedure by any payer.
Medical necessity for the procedure must be established by the patient's physician in accordance with specific payer guidelines.
The information that is being provided is for general information and should not be relied upon as definitive or comprehensive. All coding information is related to Medicare claims only. Medicaid agencies may utilize their own coding systems. Coverage rules may change from time to time. When seeking definitive information regarding coding or reimbursement it is always best to confer with your local Medicare office.
For additional information, contact our Reimbursement Department at 1-800-645-2891.
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