CMS further distinguishes vents

‘It gives them one more way of enforcement’
Friday, May 1, 2015

BALTIMORE – CMS has drawn another thick line between ventilators and Bi-level PAP devices.

The agency this week published an MLN Matters article announcing that it is revising its 855S enrollment application to make vents a separate product category.

“Right now, it’s kind of lumped in there with CPAPs and BiPAPs,” said Andrea Stark, a reimbursement consultant with MiraVista.

CMS has already published a number of bulletins clarifying the correct coding and coverage criteria for ventilators vs. Bi-level PAP devices. One big emphasis: Although the disease categories that qualify both products for coverage may appear to overlap, vents are covered only for more severe and life-threatening forms of the diseases.

By modifying the 855S form, CMS makes it clear that providers who furnish vents—not only invasive vents, but also non-invasive vents—must meet specific accreditation requirements, including “frequent and substantial servicing.”

“Providers need to meet the quality standards for invasive vents, even if they’re only providing non-invasive vents,” said Wayne van Halem, president of The van Halem Group. “They can’t drop off a non-invasive vent at a patient’s home and walk away.”

By modifying the form, CMS is also giving itself more leverage to take action against providers who aren’t in compliance with these accreditation requirements.

“It gives CMS one more way of enforcement,” Stark said. “The agency can revoke supplier numbers if providers aren’t in compliance.”

The change is most likely to affect providers that are looking at vents as a new product category and see non-invasive vents as a less intimidating way to enter the market.

“The message from CMS is you need to provide the full spectrum of vents or don’t do it at all,” Stark said.

The move is probably not CMS’s last on vents. The agency has already put non-invasive vents under widespread prepayment review and has included them in Round 1 2017 (see related story), both moves largely due to a spike in billing. The No. 1 provider of E0464, alone, received $4.5 million from Medicare in 2013, according to data obtained from CMS through a Freedom of Information Act request and featured in the HME Databank. 

What could be next: Certain stakeholders are pressing CMS to issue more specific coverage criteria for vents (there’s a National Coverage Determination, but no Local Coverage Determinations) that take into account clinical research supporting technological advancements.

“There’s no doubt this is not the last of the changes,” Stark said.