CMS steamrolls ahead with vent overhaul

Friday, November 20, 2015

BALTIMORE – Despite widespread opposition, CMS will replace five codes for ventilators with two, and reduce reimbursement significantly, says AAHomecare.

The new codes, E0465 (invasive) and E0466 (non-invasive), go into effect Jan. 1. CMS hasn’t released the fee schedule amounts yet, but Brummett says she expects the agency to make a reduction of about 33%.

“There is lots of noise about this on the Hill and we will continue to fight and see if we can get something to stick,” said Kim Brummett, vice president of regulatory affairs for the association.

CMS in June announced plans to overhaul the product category, in response to a spike in utilization for E0464.

With ventilators costing providers between $8,000 to $10,000, not including resupplies, service and maintenance, plus the costs of delivery and respiratory therapists, the new reimbursement will likely be tough to absorb, stakeholders say.

“With the current service we are providing—we have a full educational program—we’ll have to adjust like with everything else,” said Gregory LoPresti, CEO of Syracuse, N.Y.-based Upstate Home Care. “Education is important but how much can you provide (and not get paid adequately)?”

Fewer providers offering a full breadth of services—or being more selective in which patients they can afford to take care of—mean more patients getting stuck in facilities, a more expensive alternative, say stakeholders.

“Most definitely there’s going to be a cost shift,” said Bill Hart, director of clinical services for Auburn Hills, Mich.-based Advent Home Medical. “They go in into a nursing facility in a better state but in two months, they have wounds or infections that they never had before.”

Stakeholders also take issue with clarifications issued in April that sought to define criteria for Bi-level devices vs. vents, particularly a requirement that patients must need ventilation 24/7. 

“The majority of patients are not 24/7,” said Brummett. “They’ve essentially eliminated coverage for thousands of patients who are on service today, and have been on service.”

AAHomecare is meeting with consumer groups like the ALS Association to build opposition to the changes. It has also been working in support of draft legislation that would prevent CMS from making cuts to ventilator reimbursement without going through a rulemaking process and ensuring that patient access is not affected.