Some claims in limbo as Medicare clamps down on vents

Friday, September 25, 2015

YARMOUTH, Maine – HME providers are struggling with how to get paid for COPD patients who fail Bi-level PAP therapy but don’t require nearly around-the-clock ventilation.

In April, CMS issued several bulletins clarifying the coding and coverage criteria for Bi-level devices vs. vents and the aftermath, for some providers, has been denials.

“What Medicare is saying is that it needs to be a life or death situation, so if they are not on the ventilator for an extended period of time they die,” said Wayne van Halem, president of the van Halem Group. “That’s not the case with a lot of these patients, but there’s no real direction as to what to do with these patients.”

CMS has been tinkering with non-invasive ventilators since 2014, when it found a spike in utilization for E0464. In June, CMS announced plans to completely overhaul the product category.

One provider, who didn’t want to be named, said every one of his COPD patients was denied on a recent audit, even though they failed on Bi-level and continued to be hospitalized.

“The sticking point was that it wasn’t determined that they wouldn’t survive if they were off the equipment for two hours,” the provider said. “This stands to leave a large patient population with COPD without therapy.”

Stakeholders are pressing CMS to issue local coverage determinations with specific criteria for vents. Currently, there is only a national coverage determination that providers say is too general.

“The NCD is very short and to the point,” said Kevin Hill, owner of Tyler, Texas-based CPS Medical. “It’s like Bible verses—everyone reads a lot of stuff into them. What does this mean? What does that?”

That goes for contractors, too, Hill said.

“We’ve noticed we can submit two claims with identical situations,” he said. “One we win, the next we lose.”