Joint DME MAC Publication

Ventilator technology has evolved to the point where it is possible to have a single device capable of operating in numerous modes, from basic continuous positive pressure (continuous positive airway pressure [CPAP] and bi-level positive airway pressure [PAP]) to traditional pressure and volume ventilator modes. Similarly, some products add capabilities beyond these ventilator modes, to incorporate other medically necessary functions that would otherwise be performed by one or more different items. This creates the possibility that one piece of equipment may be able to replace numerous and different pieces of equipment. Equipment with multifunction capability creates the possibility of errors in claims submitted for these items. This article will discuss the application of Medicare proper coding and payment rules for ventilators.

HCPCS Coding

Effective for claims with dates of service (DOS) on or after January 1, 2016, products classified as ventilators must be billed using one of the following HCPCS codes:

E0465 - HOME VENTILATOR, ANY TYPE, USED WITH INVASIVE INTERFACE, (E.G., TRACHEOSTOMY TUBE)

E0466 - HOME VENTILATOR, ANY TYPE, USED WITH NON-INVASIVE INTERFACE, (E.G., MASK, CHEST SHELL)

For claims with DOS on or after January 1, 2019, the following ventilator code is eligible for Medicare billing:

E0467 - HOME VENTILATOR, MULTI-FUNCTION RESPIRATORY DEVICE, ALSO PERFORMS ANY OR ALL OF THE ADDITIONAL FUNCTIONS OF OXYGEN CONCENTRATION, DRUG NEBULIZATION, ASPIRATION, AND COUGH STIMULATION, INCLUDES ALL ACCESSORIES, COMPONENTS AND SUPPLIES FOR ALL FUNCTIONS

For claims with DOS on or after April 1, 2024, the following ventilator code is eligible for Medicare billing:

E0468 - HOME VENTILATOR, DUAL-FUNCTION RESPIRATORY DEVICE, ALSO PERFORMS ADDITIONAL FUNCTION OF COUGH STIMULATION, INCLUDES ALL ACCESSORIES, COMPONENTS AND SUPPLIES FOR ALL FUNCTIONS

Products previously assigned to HCPCS codes E0450 and E0463 must use HCPCS code E0465. Products previously assigned to HCPCS codes E0460, E0461 and E0464 must use HCPCS code E0466. Suppliers may access the Pricing, Data Analysis and Coding (PDAC) DMECS Product Classification List (PCL) to determine proper coding of ventilator products.

Suppliers are reminded that the payment policy requirements for the frequent and substantial servicing (FSS) payment category prohibits FSS payment for devices used to deliver continuous and/or intermittent positive airway pressure, regardless of the illness treated by the device (Social Security Act 1834(a)(3)(A)). This means that products currently classified as HCPCS code E0465, E0466, E0467, or E0468 when used to provide CPAP or bi-level PAP (with or without backup rate) therapy, regardless of the underlying medical condition, may not be paid in the FSS payment category. General principles of correct coding require that products assigned to a specific HCPCS code only be billed using the assigned code. Thus, using the HCPCS codes for CPAP (E0601) or bi-level PAP (E0470, E0471) devices for a ventilator used to provide CPAP or bi-level PAP therapy is incorrect coding. Claims for ventilators billed using the CPAP or bi-level PAP device HCPCS codes will be denied as incorrect coding.

There are additional requirements related to billing of codes E0467 and E0468.

Code E0467 describes a multi-function ventilator that combines the function of a ventilator with all of the following for (4) additional functions:

• Oxygen concentrator,
• Nebulizer,
• Aspirator, and
• Cough stimulator.

Code E0468 describes a multi-function ventilator that combines the function of a ventilator with the following one (1) additional function:

• Cough stimulator.

Note: If the device is a multifunction ventilator but it does not combine the function of a ventilator with each of the functions listed above, then the supplier must code the multi-function ventilator as E1399 (DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS) on their claim. When billing with code E1399, the supplier must enter a description of the item which includes all functions of the device, manufacturer name, product name/number, supplier price list, and HCPCS of related item in loop 2300 (claim note) and/or 2400 (line note), segment NTE02 (NTE01=ADD) of the ANSI X12N, version 5010A1 professional electronic claim format or in Item 19 of the paper claim form.

The following HCPCS codes for individual items are included in the functionality of multi-function ventilators coded E0467 or represent similar equipment used for the same or similar purpose:

• 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)

The following HCPCS codes for individual items are included in the functionality of multi-function ventilators coded E0468 or represent similar equipment used for the same or similar purpose:

• 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)

For E0467 claims with dates of service before April 3, 2020:

Claims for any of the HCPCS codes listed above that are submitted on the same claim or that overlap any date(s) of service for E0467 is considered to be unbundling.

In addition, any claim for repair (HCPCS code K0739 for labor and any HCPCS code for replacement items) of beneficiary-owned equipment identified by HCPCS codes listed above is considered as unbundling if the date(s) of service for the repair overlaps any date(s) of service for code E0467.

Claims for code E0467 with a date(s) of service that overlaps date(s) of service for any of the following scenarios are considered as a claim for same or similar equipment when the beneficiary:

• Is currently in a rental month for any of the items listed above
• Owns any of the equipment listed above that has not reached the end of its reasonable useful lifetime.

For E0467 claims with dates of service on or after April 3, 2020:

Any claim for repair (HCPCS code K0739 for labor and any HCPCS code for replacement items) of beneficiary-owned equipment identified by HCPCS codes listed above is considered as unbundling if the date(s) of service for the repair overlaps any date(s) of service for code E0467.

Claims for code E0467 with a date(s) of service that overlaps date(s) of service in a rental month for any of the items listed above are considered as a claim for same or similar equipment.

Suppliers are encouraged to be sure that the correct category of product is provided and billed to avoid errors in HCPCS coding.

Upgrades

An upgrade is defined as an item that goes beyond what is medically necessary under Medicare's coverage requirements. In some cases, CMS policy that allows for billing of upgrade modifiers can be used when providing an item or service that is considered beyond what is medically necessary. This is not applicable to ventilators in the situations described above.

Although the use of a ventilator to treat any of the conditions contained in the PAP or RAD LCD is considered "more than is medically necessary," the upgrade billing provisions may not be used to provide a ventilator for conditions described in the PAP or RAD LCD. CPAP and bi-level PAP items are in the Capped Rental payment category while ventilators are in the FSS payment category. Upgrade billing across different payment categories is not possible. Claims for items billed for upgrade across different payment categories will be rejected as unprocessable.

Payment Category

Ventilators are classified in the FSS payment category. FSS items are those for which there must be frequent and substantial servicing in order to avoid risk to the patient's health (Social Security Act §1834(a)(3)(A)). The monthly rental payment for items in this pricing category is all-inclusive meaning there is no separate payment by Medicare for any options, accessories or supplies used with a ventilator. In addition, all necessary maintenance, servicing, repairs and replacement are also included in the monthly rental. Claims for these items and/or services will be denied as unbundling.

CMS establishes fee schedule amounts for multi-function ventilators in accordance with regulations at 42 CFR 414.222(f)(2) and (f)(3).

Payment of Second Ventilator

Medicare does not pay for spare or back-up equipment. Claims for backup equipment will be denied as not reasonable and necessary - same/similar equipment.

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 beneficiary. Although Medicare does not pay separately for backup equipment, Medicare will make a separate payment for a second piece of equipment if it is required to serve a different medical purpose that is determined by the beneficiary's medical needs.

The following are examples of situations in which a beneficiary would qualify for both a primary ventilator and a secondary ventilator:

• A beneficiary 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. positive pressure ventilator with a nasal mask) during the rest of the day.
• A beneficiary 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 two pieces of equipment, the beneficiary 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.

Refer to the various LCDs and LCD-related Policy Articles referenced above as impacted and to the DME MAC Supplier Manuals for additional information on coverage, coding and documentation of these items.

For questions about correct coding, contact the PDAC HCPCS Helpline at (877) 735-1326 during the hours of 9:30 a.m. to 5:00 p.m. ET, Monday through Friday. You may also visit the PDAC website to chat with a representative or select the Contact Us button at the top of the PDAC website for email, FAX, or postal mail information.

Revision History

Date	Update
05/16/2024	Published on PDAC website