RAD reimbursement comes under attack

Sunday, August 31, 2003

WASHINGTON - The HME industry has begun pulling together clinical evidence to show that non-invasive ventilation with back-up should remain in the frequent-and-substantial reimbursement category and not become a capped rental item as CMS seems intent on making it.

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, say industry sources.

The frequent-and-substantial payment category lasts for the life of the patient. The capped rental period, except for a small maintenance stipend, ends after 15 months.

“Most of these patients need to be seen mon-thly and evaluated,” said Bob Fary, Apria’s corporate director of respiratory service. “Who responds at 1 a.m. if the device fails and there is not a rental relationship between the provider and patient?”

Industry watchers expect the proposed change from frequent and substantial to capped rental to appear in the Federal Registrar some time this year.

Once that happens, there will be a comment period during which the industry can present clinical evidence as to why the code should not be changed. Fary, AAHomecare and others are working to assemble that evidence.

In proposing the change, CMS seems to be standing on a belief that devices in the K0533 code are reliable and don’t require frequent-and-substantial service. Also, in a 2001 report, the OIG claimed the switch to capped rental would save CMS $11.5 million a year. There’s also a feeling that some patients on these non-invasive devices, rather than needing to see a provider once a month or so, simply enjoy they company of a respiratory therapist, a DMERC offical told HME News.

“And what about the patients they don’t see every month?” the DMERC source said. “I would wager there are a lot of patients like that.”

As such, there is no reason the K0533 code needs to be in the frequent-and-substantial reimbursement category, which is reserved for devices that if they failed, the patient would need immediate attention, maintain DMERC, OIG and CMS officials.

That kind of reasoning doesn’t sit well with Joe Lewarski, president of Hytech Homecare & Medical Supply in Mentor, Ohio.

Although the government doesn’t pay for care in DME, it is clearly subsidized through the frequent-and-substantial payment category, and patients on ventilators, both invasive and non-invasive, get a majority of their care from a DME’s respiratory therapist, Lewarski said.

To make the K0533 a capped rental would be a “horrible” move, Lewarski added.

“To me it is not in the best interest of the patient and promotes bad patient care,” Lewarski said. “It sends a bad message that the government’s sole intent is to reduce payment.” HME