Discretion, clinical expertise essential for NPPV success
Non-invasive positive pressure ventilation therapy isn't for everybody, whether it be patients or providers. For patients, the issue is whether they qualify for treatment. For providers, it's about the qualifying process.
Ever since CMS raised the clinical evidence threshold for Respiratory Assistive Devices (RADs) and mandated overnight oximetry tests for patients (which providers are prohibited from conducting themselves), a market that once generated $50 million to $80 million annually is now considered to be no more than a sideline by many providers.
NPPV mainly benefits those who have trouble breathing when they are asleep. Typically these are people who suffer from chronic obstructive pulmonary disease or neuromuscular disorders, said respiratory consultant Allan Saposnick.
"There are specific patients for whom NPPV makes a lot of sense," said Saposnick, president of Newtown Square, Pennsylvania-based ABSCO Enterprises. "It is appropriate for patients who hypoventilate when they sleep. These are patients who do fairly well during the day, but need extra respiratory support at night."
The need for NPPVs may be there, but rigid patient qualifying criteria for Medicare and private insurance has created a climate of reluctance among respiratory providers.
"I think a lot of [providers] are really intimidated by this area, particularly when it comes to Medicare patients," said Phil Carter, HME manager at Wilcox Pharmacy in Ludlow, Vt. "There are very stringent requirements, and a lot of hospitals and physicians don't want to deal with the overnight testing and all the documentation. They'd rather just find a different way to treat the patient."
The fact remains though, that NPPV is the best recourse for a specific set of patients, Saposnick said, and despite the difficulty in obtaining coverage, providers should continue pursuing that treatment for those patients.
"There are specific steps you have to show to get reimbursement – such as if someone has restrictive lung disease where breathing is affected by non-pulmonary problems, such as thoracic deformity," Saposnick said. "Another is excessive carbon dioxide build-up that causes inability to oxygenate effectively.
"Most insurers will reimburse for BiPAP, and NPPV is really BiPAP with a time element to it," he continued. That is the way respiratory sales people should approach the physician. If they have a patient not doing well on CPAP or BiPAP, NPPV is the next step. It's a quality of life issue and the referral source should be educated by the provider about that, Saposnick said.
Although patients aren't going on NPPV "at nearly the rate they used to," the market "has remained pretty steady" for patients with neuromuscular disease, said Bob Fary, corporate director of respiratory services for Lake Forest, California-based Apria.
"These patients have been on this kind of therapy for a long time and will continue to be," he said. "The change has been that a lot of COPD patients were going on NPPV until the qualification process was changed, so they aren't going on it at nearly the rate they used to."
Providers who want to boost their NPPV services need to cultivate relationships with physicians who specialize in neuromuscular disease and with non-profit organizations that serve those populations, Fary said.
"They need to show their expertise in caring for that type of patient to get those referrals," he said. "They also need to get involved with the muscular dystrophy clinics, the ALS Society, and also get involved with local and regional chapters of neuromuscular disease organizations."
Physicians and respiratory therapists in the San Antonio market are consistently requesting NPPV therapy and Hope Medical Supply accommodates those referrals. However, the company is more or less ambivalent about aggressively seeking that business, says Vice President Albert Vale
"It's a tough decision because this market falls into a gray area," he said. "We are getting pushed in this direction [by referral sources], but we don't get reimbursed for many of the things they ask us to do. On top of that, there is the Joint Commission and others who say if you participate, you need to follow their standards and regulations. Nobody has a clear idea of how it's supposed to be done."
Indeed, the NPPV reimbursement formula can make it tough for respiratory providers to serve these patients without losing money. Even a savvy respiratory veteran like Joe Lewarski says current conditions have reduced NPPV to little more than a niche market for his company.
"Respiratory providers will always promote their ability to do [NPPV], but it is not a significant portion of our revenue mix, and I wouldn't hang my hat on it," said Lewarski, president of Mentor, Ohio-based Hytech Homecare. "It's just not a high volume business."
Still, familiarity with Medicare NPPV codes can help providers make the best discretionary decisions in treating patients, Lewarski said. For instance, a key difference between the K0532 and K0533 codes is that the K0533 covers a RAD with a backup rate, while the K0532 does not. That aspect makes a big difference in the reimbursement rate, he said.
"The K0532 is a capped rental, reimbursement is inadequate for the work you do and is generally a disservice to the patient," Lewarski said. "Reimbursement for the K0533 is adequate over time, but very few qualify for it."
Because there has been substantial research done on neuromuscular patients, getting the necessary documentation to put them on NPPV therapy is much easier than for COPD patients, Lewarski said.
"Historically we have gotten a lot of clinical evidence to support NPPV use for neuromuscular patients," he said. "That's not so for COPD patients, where research has been lacking."
Vale concedes that Hope Medical has the capabilities to provide NPPV and that "the modality should be used more." Still, unless Medicare reimbursement increases and the stiff regulations are lifted, NPPV is not likely to regain its former prominence, he said.
"It's time for Medicare to step up and pay for these services instead of always putting it on the backs of the providers," Vale said. HME