CMS Expands Use of Multi-Function Ventilators

New MLN Matters article stipulates that beneficiaries must now only meet typical coverage for a ventilator.

Effectively immediately, DMEPOS suppliers can provide and bill for multi-function ventilators (HCPCS code E0467) as an upgrade when beneficiaries only meet the typical coverage criteria for a ventilator, according to a new CMS MLN Matters Article.

Previously, a beneficiary had to qualify for both a ventilator and at least one of four additional functions: oxygen concentrator, cough stimulator, suction pump, or nebulizer. Now the beneficiary must only qualify for the ventilator alone.

To collect for the upgrade, suppliers must obtain a properly completed Advance Beneficiary Notice (ABN), according to the CMS article. Also, the supplier must bill the codes in a specific order on the claim. On one claim line the supplier bills with a GA modifier the HCPCS code that describes the item (E0467) and on the next claim line, the supplier bills with a GK modifier the HCPCS code (in this case E0465 or E0466) that describes the item that is covered based on the LCD.

From the article:

“In this situation, the claim line with the GA modifier will be denied as not medically necessary with a ‘Patient Responsibility’ (PR) message, and the claim line with the GK modifier will continue through the usual claims processing. The beneficiary liability will be the sum of (a) the difference between the submitted charge for the GA claim line and the submitted charge for the GK claim line and (b) the deductible and co-insurance that relate to the allowed charge for the GK claim line.”

CMS's article also provides additional guidelines if the supplier opts to provide the upgrade at no additional charge.

The full article is at www.cms.gov/files/document/se20012.pdf.

About the Author

David Kopf is the Publisher and Executive Editor of HME Business and DME Pharmacy magazines. Follow him on Twitter at @postacutenews.

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