CMS, industry gear up for NPPV fight

Friday, October 31, 2003

WASHINGTON - A CMS proposal to reduce reimbursement for non-invasive positive pressure ventilation (NPPV) with back-up has rankled providers and other industry types.

In proposing the change from frequent and substantial to the less costly capped-rental category, CMS appears motivated by an opportunity to save money - not to do what’s right for the patient, say industry watchers.

“This is not a large portion of Medicare’s spending, and this is not the place to go find dollars,” said Joe Lewarski, president of Hytech Homecare & Medical Supply in Mentor, Ohio. “I think you are going to see a fight.”

AAHomecare as well physician and clinical groups have begun formulating responses against the proposal, Lewarski said.

Ever since CMS raised the threshold for who qualifies for respiratory-assist devices (RAD) in the K0533 code several years ago, the therapy has become more or less a niche market for patients with degenerative neuromuscular diseases, patients whose conditions will continue to worsen. Switching the code to capped rental would remove the incentive for providers to furnish the necessary ongoing care such patients require once the capped rental period ends.

In a 2001 report, the OIG claimed the switch to capped rental would save CMS $11.5 million a year.

CMS believes, based on the OIG report, that units in the K0533 category were improperly coded as therapeutic ventilators when the code was first created. CMS also believes that the switch in payment levels will not result in a decrease in current patient service levels.

The industry disagrees.

Some even question CMS’s authority to change the payment category for NPPV. In the Six-Point Plan, Congress specified that payment for ventilators be in the frequent-and-substantial category, said Ron Billingsley, director of government relations for Respironics,

“The product is designed to help very sick respiratory patients, and to leave them on their own and to say it doesn’t require ongoing maintenance is a mistake,” Billingsley added.