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The Changing Landscape of Adult Home Noninvasive Ventilation Technology, Use, and Reimbursement in the United StatesA Practice Management Perspective FREE TO VIEW

Bernie Y. Sunwoo, MBBS; Mary Mulholland, MHA, BSN RN, CPC; Ilene M. Rosen, MD, MSCE; Lisa F. Wolfe, MD, FCCP
Author and Funding Information

From the Department of Medicine (Drs Sunwoo and Rosen), Division of Pulmonary, Allergy and Critical Care Medicine, Division of Sleep Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; the Department of Medicine (Ms Mulholland), Hospital of the University of Pennsylvania, Philadelphia, PA; the Division of Pulmonary and Critical Care Medicine (Dr Wolfe), Northwestern University Feinberg School of Medicine, Chicago, IL.

Correspondence to: Bernie Y. Sunwoo, MBBS, Perelman School of Medicine, University of Pennsylvania, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Division of Sleep Medicine, Perelman Center for Advanced Medicine, 1st Floor, W Pavilion, 3400 Civic Center Blvd, Philadelphia PA 19104; e-mail: bernie.sunwoo@uphs.upenn.edu


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(5):1134-1140. doi:10.1378/chest.13-0802
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There has been an exponential increase in the use of home noninvasive ventilation (NIV). Despite growing use, there is a paucity of evidence-based guidelines and practice standards in the United States to assist clinicians in the initiation and ongoing management of home NIV. Consequently, home NIV practices are being influenced by complicated local reimbursement policies and coding. This article aims to provide a practice management perspective for clinicians providing home NIV, including Local Coverage Determination reimbursement criteria for respiratory assist devices, Durable Medical Equipment coding, and Current Procedural Terminology coding to optimize clinical care and minimize lost revenue. It highlights the need for further research and development of evidence-based clinical practice standards to ensure best practice policies are in place for this rapidly evolving patient population.

There has been an exponential increase in the use of home noninvasive ventilation (NIV). Driven in part by advances in sleep medicine and the demonstrated efficacy in 1981 of CPAP to treat OSA, NIV is progressively replacing tracheostomy and invasive mechanical ventilation in the home. CPAP (E0601) refers to application of continuous positive pressure throughout the respiratory cycle in a spontaneously breathing individual. It is used primarily to treat OSA and hypoxemia. CPAP is distinct from NIV, which is intended to increase alveolar ventilation, and is considered separate from NIV in this article.

Prevalence data on home NIV use in the United States are lacking. No national database or registry exists, and most prevalence estimates are extrapolations from insurance claims or hospital surveys. In 2010, based on Centers for Medicare and Medicaid Services (CMS) claims data, approximately 47,981 CMS patients were estimated to be receiving some form of home ventilation in the United States, with approximately 6.6% using invasive ventilation.1 With ongoing technologic advances in noninvasive ventilators and interfaces, increasing numbers of patients surviving critical illness, evidence supporting a growing list of disorders that can be successfully managed by NIV, and economic pressures, it is anticipated that home NIV use will continue to grow.

Despite the growing use of home NIV, with the exception of certain neuromuscular disorders, such as Duchenne muscular dystrophy and amyotrophic lateral sclerosis,2,3 there is a paucity of evidence-based guidelines and practice standards in the United States to assist clinicians in the initiation and ongoing management of home NIV. Consequently, home NIV practices are being influenced by complicated local reimbursement policies. This article aims to provide a practice management perspective for clinicians providing home NIV, including coverage, coding, and reimbursement to optimize clinical care and minimize lost revenue.

Much of the increase in home NIV use has been fueled by technologic advances in noninvasive ventilators and interfaces. Home NIV ventilators are generally positive pressure devices, and although negative pressure devices like the chest cuirass exist, they are rarely used, and for the purposes of this article will not be reviewed. Noninvasive ventilators vary in design characteristics depending on their intended purpose of use. Traditional critical care ventilators designed for invasive mechanical ventilation are characterized by dual-limb circuits with an active exhalation valve and sophisticated modes and alarms. They are typically labeled as “ventilators” by the reimbursement community and will be denoted critical care ventilators (CCVs) in this article. In contrast, respiratory assist devices (RADs) or portable “bilevel devices” are designed for home noninvasive ventilation use1 and are the focus of this article.

RADs use a single-limb circuit with a passive exhalation port incorporated into the circuit and allow for better leak compensation. Bilevel devices can be spontaneous (E0470) or have a backup rate (E0471). Newer autotitrating devices that change pressure support based on feedback from various patient parameters using proprietary algorithms are becoming available. In adaptive servoventilation, the degree of ventilatory support is dynamically adjusted breath to breath to stabilize minute ventilation and is used in patients with central and complex sleep apnea.47 The compact size, lower cost, and portability of RADs have made them more appealing for use at home.

Although traditionally CCVs and RADs varied in the features offered, technologic developments have blurred the distinction between the two. RADs are becoming increasingly sophisticated, whereas newer-generation CCVs allow for better leak compensation and noninvasive use.8 This has created confusion as to what exactly constitutes a CCV or RAD, challenging coding and reimbursement. Although CCVs were originally designed for patients requiring full invasive mechanical ventilatory support or “life support” and RADs for patients requiring no or partial ventilatory support, the practice of associating the type of ventilator to the degree of ventilator dependence or type of interface is no longer always applicable with the recent US Food and Drug Administration approval of a RAD for use with a tracheostomy.1 This RAD device also falls under the category of a CCV and, like other CCVs, has an active exhalation valve, internal battery source, and alarms to address safety. Similarly, the recent US Food and Drug Administration approval of advanced E0471 devices marketed for specific conditions, such as COPD, was based on built-in alarms. Conversely, CCVs can function to provide home NIV. Life support is often presumed to mean ventilator dependence, where cessation can be life threatening, but no uniform definition exists. With this ambiguity in what constitutes ventilator dependence, it is not entirely clear when to prescribe a CCV vs an RAD.

The home NIV population is becoming increasingly heterogeneous, with an expanding list of medical indications for NIV. NIV has been shown to improve survival, palliate symptoms, and improve quality of life in patients with neuromuscular disease, including amyotrophic lateral sclerosis and Duchenne muscular dystrophy.2,911 Similarly, prolonged survival and reduced morbidity have been demonstrated in scoliosis and restrictive chest wall disease.12,13 The evidence for NIV in stable COPD has been inconsistent,1416 but COPD is a frequent cause for home NIV use worldwide.17 There is growing interest in the role of NIV in the overlap syndrome or coexisting COPD and OSA,18 whereas sleep-related breathing disorders and the obesity hypoventilation syndrome (OHS) have become leading indications for home NIV.19,20 The risk of OSA and OHS increases with obesity, and in the United States it is now estimated that more than one-third of adults are obese.21 An OHS prevalence of 10% to 20% has been reported in obese patients with OSA.22 OHS was the leading indication for home NIV, responsible for 31%, in a recent study exploring prevalence and patterns of home mechanical ventilation in Australia and New Zealand.23

With escalating NIV use and costs, in 1998 a consensus conference was convened by the National Association for Medical Direction of Respiratory Care to develop practice guidelines for NIV use. Subsequently, a consensus report was published describing clinical indications for NIV in restrictive thoracic disorders, including neuromuscular disorders, COPD, and nocturnal hypoventilation syndromes.24 The report was adopted by CMS and then secondarily by third-party carriers and serves as the guide for most current home NIV reimbursement coverage policies today. CMS coverage is executed with a trickle-down model by which a central federal plan, known as National Coverage Determination, is developed. The CMS awarded contracts to four regional Durable Medical Equipment (DME) Medicare Administrative Contractors to develop and administer slightly different versions of the National Coverage Determination, referred to as Local Coverage Determinations (LCDs) (Table 1).25 LCDs determine qualifications for RAD approval, but there may be variation between third-party payers. Additionally, although LCDs determine RAD prescription qualifications regionally, Medicaid reimbursement varies state to state.26

Table Graphic Jump Location
Table 1 — Durable Medical Equipment Medicare Administrative Contractors

Data from Manaker and Pohlig.25 Ph = phone.

Again, loosely based on the 1999 consensus report, most CMS and third parties have specific initial coverage criteria for RADs for different underlying clinical disorders, typically grouped under restrictive thoracic disorders, severe COPD, central or complex sleep apnea, and hypoventilation syndromes. Different coverage criteria for bilevel positive airway pressure (BPAP) to treat OSA exist (Table 2).26,27 BPAP units with a backup rate (E0471) are not reimbursed for the treatment of OSA in the absence of concomitant central events. Current LCDs do not make allowance for the advances in home NIV since 1999 and more recent studies exploring more novel applications of NIV, such as in pulmonary rehabilitation.8 Reimbursement coverage criteria for CCVs are separate and not reviewed in this article.

Table Graphic Jump Location
Table 2 —Initial Reimbursement Coverage Criteria for Respiratory Assist Devices

ABG = arterial blood gas; AHI = apnea-hypopnea index; PAP = positive airway pressure; PSG = polysomnogram; RDI = respiratory disturbance index; Spo2 = oxygen saturation as measured by pulse oximetry.

a 

Includes out-of-center sleep testing and home sleep testing.

b 

The treating physician is required to address and document interface fit and comfort and CPAP pressure settings including a trial and failure of lower settings to adequately control symptoms, improve sleep quality, or reduce AHI/RDI to acceptable levels before determining CPAP ineffective. During the initial 3-mo trial, substitution to an E0470 does not require a new initial face-to-face clinical evaluation or a new sleep test. Switching to an E0470 after > 3 mo of CPAP use requires a new face-to-face clinical evaluation but not a new sleep test.

Similarly, separate criteria exist for continued coverage of RADs beyond 3 months for OSA and other clinical indications. For OSA, there needs to be reevaluation by the treating physician, with signed and dated documentation no sooner than 31 days but no later than 91 days after initiation of therapy. Continued coverage requires ≥ 4 h of use per night on 70% of nights during a consecutive 30-day period during the first 3 months of initial usage. In contrast, continued coverage of a RAD beyond 3 months for indications other than OSA requires reevaluation by the treating physician with signed and dated documentation no sooner than 61 days after initiation of therapy. Documentation of an average of 4 h of use per 24-h period and improvement in relevant symptoms but no download data are required. If not met, continued coverage will be denied as medically not necessary.

Home NIV falls under the category of DME or home medical equipment. DME is typically covered by the patient’s health-care insurance and begins with a prescription through a licensed DME provider. This provider may be independent or owned and operated by a health insurance company, hospital system, or physician cooperative. Until recently, patients under CMS were entitled to choose any DME provider for their RAD. This is no longer the case with the CMS expansion of the Medicare DME, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program. Under the Competitive Bidding Program, DMEPOS suppliers compete to become Medicare contract suppliers. Bids to furnish items in competitive bidding areas, including RADs and related accessories, are submitted with the goal of lowering payment amounts for DMEPOS items through competition and replacing Medicare DMEPOS fee schedule amounts.28 Information on participation locations is available from CMS.29 The Competitive Bidding Program does not yet apply to CCVs.

DME is coded and billed using CMS Healthcare Common Procedure Coding System (HCPCS) codes, and familiarity with the coding and reimbursement policies is just as important as familiarity with the various ventilators and interfaces to avoid denials of necessary equipment and lost revenue. The HCPCS codes were developed to provide a standardized system for billing supplies and are required by the Health Insurance Portability and Accountability Act of 1996.25 Common HCPCS codes for home noninvasive ventilators and accessories are provided in Table 3, with separate codes for CCVs and RADs.

Table Graphic Jump Location
Table 3 —Health-care Common Procedure Coding System Codes for Home Noninvasive Ventilation Equipment

Data from Manaker and Pohlig.25 HCPCS = Healthcare Common Procedure Coding System. See Table 2 legend for expansion of other abbreviation.

Under CMS, payment for CCVs with alarms and internal batteries falls under DME “requiring frequent and substantial servicing.” Payments are made on a monthly rental basis as long as medical necessity exists and are accompanied by respiratory care services and patient education. In contrast, RADs are paid as capped rental items. CMS provides a set monthly payment for 13 months only, after which there is no further payment, and ownership of the RAD can be transferred to the Medicare beneficiary. The same degree of clinical respiratory support is typically not provided, highlighting the dangers in a reimbursement system based on type of ventilator device rather than clinical needs. Additionally, claims for a backup ventilator or external battery source are often denied despite ventilator dependence in a subset of patients using RADs for whom the consequences of a power failure or mechanical malfunction are potentially catastrophic.

Home NIV accessories including reusable mask interfaces are typically covered by CMS and third parties at variable intervals as determined by DME Medicare Administrative Contractor by State.25 Once again, familiarity with the LCD-determined quantity and frequency of necessary accessories and supplies is essential to avoid denied payments (Table 3).

Successful home NIV management goes beyond mere provision of DME. It requires a comprehensive clinical evaluation and follow-up, but the degree of clinical and technical support needed is extremely variable given the mixed indications for home NIV. Potentially, patients with home NIV are among the most complicated of patients, requiring the coordinated efforts of an interdisciplinary team involving physicians, nurses, respiratory therapists, and other home-care services. Coding for these services to ensure appropriate payment is equally complex.

Current Procedural Terminology (CPT) codes were developed by the American Medical Association (AMA) in an attempt to provide a uniform description of medical and diagnostic services and form the basis for reimbursement by third-party payers. CPT codes are copyrighted by the AMA and can be found in Current Procedural Terminology, published by the AMA.30 A comprehensive review of CPT codes is also available in Coding for Chest Medicine 2013, published by the American College of Chest Physicians (ACCP).25 The wide spectrum of ventilator dependence and services required by the heterogeneous home NIV population limits the generalized application of these codes.

In the majority of patients using RADs, Evaluation and Management (E/M) coding will be used for patient visits with physicians and qualified nonphysician practitioners. A CPT code for CPAP or BPAP initiation, CPT 94660, exists. CPT 94660 was originally a hospital code intended for CPAP initiation in the ICU. The face-to-face physician and technician time (42 min supervised) required for appropriate use of this code is high. The code cannot be billed with an E/M service code on the same day. Additionally, CMS and third parties require documentation of positive airway pressure (PAP) adherence with PAP downloads for continued coverage, but this service is not covered, even when coded using CPT 99090 for analysis of clinical data stored in computers. In contrast, when download data are reviewed for CCVs, the service can be reported as part of CPT 94005.

Patients using CCVs require additional services, and although CPT codes exist for the provision of some of these services, many are not currently reimbursed by CMS. CPT 94005 describes home ventilator management care plan oversight of a patient.30 CPT 94005 is currently not recognized by CMS and cannot be billed with an E/M service on the same calendar day. On the other hand, Prolonged Care service codes, CPT 99354-99355, can be used in addition to E/M services for complex NIV cases. CPT 99354-99355 are time-based outpatient codes for use when the physician’s service extends beyond the typical time associated with the visit provided. It can be billed only if the total duration of all direct face-to-face service equals or exceeds the threshold time for the provided E/M service (typical/average time associated with the CPT E/M plus 30 min).25

In 2013, Complex Chronic Care Coordination (CCCC) and Transitional Care Management (TCM) codes were introduced to better describe the complexities of caring for patients with chronic disorders. Currently, TCM codes are reimbursed by CMS, but CCCC codes are not. In July 2013, the CMS issued a proposed rule for separate payment for complex chronic care management services under the Physician Fee Schedule beginning 2015, but it remains unclear whether the proposed change will be approved in the CMS Final Rule.31 CCCC codes (CPT 99487-99489) are patient-centered management and support services provided by physicians and other qualified health-care professionals to an individual at home or in a domiciliary, rest home, or assisted living facility that address the coordination of care by multiple disciplines and community service agencies, as needed, for all medical conditions, psychosocial needs, and activities of daily living. CCCC codes are currently not reimbursed by CMS but may be reimbursed by third-party payers. Nonetheless, CCCC codes should be reported if they accurately describe the services provided in caring for patients with home NIV. If within 30 days of discharge, TCM codes may be appropriate instead.

TCM codes, CPT 99495-99496, are used to report services for an established patient whose medical problems require moderate or high complexity medical decision-making during transitions in care from an inpatient hospital setting, observation status in a hospital, skilled nursing facility, or nursing facility to the patient’s home setting. TCM services begin on the date of discharge and may be reported only once within 30 days of discharge. CPT 99495 requires medical decision-making of at least moderate complexity as defined by the E/M Services guidelines, communication with the patient and/or caregiver within 2 business days of discharge, and a face-to-face visit within 14 calendar days of discharge. CPT 99496 requires medical decision-making of high complexity and a face-to-face visit within 7 calendar days of discharge. Unlike CCCC, TCM codes are recognized and reimbursed by CMS, and additional E/M services may be reported after the first face-to-face visit separately.

Home NIV technology and use is evolving and crossing traditional boundaries of ventilatory support, revealing limitations in the current coding and reimbursement policies for home NIV. As home NIV technology continues to develop, further research and development of evidence-based clinical practice standards are needed to ensure best practice policies are in place for this ever-growing patient population.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Rosen serves on the board of directors for the American Academy of Sleep Medicine, is a member of the ACGME Residency Review Committee for Internal Medicine, and receives royalties from UpToDate, Inc for a chapter on oxygen consumption and delivery. Dr Wolfe receives grant/research support from ResMed and serves as a consultant for Koninklijke Philips NV, and Hill-Rom. Dr Sunwoo and Ms Mulholland have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: We thank Scott Manaker, MD; Kelly Carden, MD; William Charles Sherrill, MD; and Carolyn Winter-Rosenberg for their assistance in the preparation of this manuscript.

AMA

American Medical Association

BPAP

bilevel positive airway pressure

CCCC

Complex Chronic Care Coordination

CCV

critical care ventilator

CMS

Centers for Medicare and Medicaid Services

CPT

Current Procedural Terminology

DME

Durable Medical Equipment

DMEPOS

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies

E/M

Evaluation and Management

HCPCS

Healthcare Common Procedure Coding System

LCD

Local Coverage Determination

NIV

noninvasive ventilation

OHS

obesity hypoventilation syndrome

PA

positive airway pressure

RAD

respiratory assist device

TCM

Transitional Care Management

King AC. Long-term home mechanical ventilation in the United States. Respir Care. 2012;57(6):921-930. [CrossRef] [PubMed]
 
Finder JD, Birnkrant D, Carl J, et al; American Thoracic Society. Respiratory care of the patient with Duchenne muscular dystrophy: ATS consensus statement. Am J Respir Crit Care Med. 2004;170(4):456-465. [CrossRef] [PubMed]
 
Miller RG, Jackson CE, Kasarskis EJ, et al; Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter update: the care of the patient with amyotrophic lateral sclerosis: drug, nutritional, and respiratory therapies (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2009;73(15):1218-1226. [CrossRef] [PubMed]
 
Aurora RN, Chowdhuri S, Ramar K, et al. The treatment of central sleep apnea syndromes in adults: practice parameters with an evidence-based literature review and meta-analyses. Sleep. 2012;35(1):17-40. [PubMed]
 
Sharma BK, Bakker JP, McSharry DG, Desai AS, Javaheri S, Malhotra A. Adaptive servoventilation for treatment of sleep-disordered breathing in heart failure: a systematic review and meta-analysis. Chest. 2012;142(5):1211-1221. [CrossRef] [PubMed]
 
Morgenthaler TI, Gay PC, Gordon N, Brown LK. Adaptive servoventilation versus noninvasive positive pressure ventilation for central, mixed, and complex sleep apnea syndromes. Sleep. 2007;30(4):468-475. [PubMed]
 
Allam JS, Olson EJ, Gay PC, Morgenthaler TI. Efficacy of adaptive servoventilation in treatment of complex and central sleep apnea syndromes. Chest. 2007;132(6):1839-1846. [CrossRef] [PubMed]
 
Hess D. Positive pressure ventilators.. In:Elliott M, Nava S, Schonhofer B., eds. Non-invasive Ventilation and Weaning: Principles and Practice. London, England: Edward Arnold Publishers Ltd; 2010:13-24.
 
Bourke SC, Tomlinson M, Williams TL, Bullock RE, Shaw PJ, Gibson GJ. Effects of non-invasive ventilation on survival and quality of life in patients with amyotrophic lateral sclerosis: a randomised controlled trial. Lancet Neurol. 2006;5(2):140-147. [CrossRef] [PubMed]
 
Bach JR, Martinez D. Duchenne muscular dystrophy: continuous noninvasive ventilatory support prolongs survival. Respir Care. 2011;56(6):744-750. [CrossRef] [PubMed]
 
Simonds AK, Muntoni F, Heather S, Fielding S. Impact of nasal ventilation on survival in hypercapnic Duchenne muscular dystrophy. Thorax. 1998;53(11):949-952. [CrossRef] [PubMed]
 
Annane D, Orlikowski D, Chevret S, Chevrolet JC, Raphaël JC. Nocturnal mechanical ventilation for chronic hypoventilation in patients with neuromuscular and chest wall disorders. Cochrane Database Syst Rev. 2007;;(4):CD001941.
 
Gustafson T, Franklin KA, Midgren B, Pehrsson K, Ranstam J, Ström K. Survival of patients with kyphoscoliosis receiving mechanical ventilation or oxygen at home. Chest. 2006;130(6):1828-1833. [CrossRef] [PubMed]
 
Kolodziej MA, Jensen L, Rowe B, Sin D. Systematic review of noninvasive positive pressure ventilation in severe stable COPD. Eur Respir J. 2007;30(2):293-306. [CrossRef] [PubMed]
 
McEvoy RD, Pierce RJ, Hillman D, et al; Australian trial of non-invasive Ventilation in Chronic Airflow Limitation (AVCAL) Study Group. Nocturnal non-invasive nasal ventilation in stable hypercapnic COPD: a randomised controlled trial. Thorax. 2009;64(7):561-566. [CrossRef] [PubMed]
 
Windisch W, Haenel M, Storre JH, Dreher M. High-intensity non-invasive positive pressure ventilation for stable hypercapnic COPD. Int J Med Sci. 2009;6(2):72-76. [CrossRef] [PubMed]
 
Lloyd-Owen SJ, Donaldson GC, Ambrosino N, et al. Patterns of home mechanical ventilation use in Europe: results from the Eurovent survey. Eur Respir J. 2005;25(6):1025-1031. [CrossRef] [PubMed]
 
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Sullivan CE, Issa FG, Berthon-Jones M, Eves L. Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares. Lancet. 1981;1(8225):862-865. [CrossRef] [PubMed]
 
Priou P, Hamel JF, Person C, et al. Long-term outcome of noninvasive positive pressure ventilation for obesity hypoventilation syndrome. Chest. 2010;138(1):84-90. [PubMed]
 
Adult overweight and obesity. Centers for Disease Control and Prevention website. http://www.cdc.gov/obesity/adult/index.html. Accessed January 27, 2013.
 
Mokhlesi B. Obesity hypoventilation syndrome: a state-of-the-art review. Respir Care. 2010;55(10):1347-1362. [PubMed]
 
Garner DJ, Berlowitz DJ, Douglas J, et al. Home mechanical ventilation in Australia and New Zealand. Eur Respir J. 2013;41(1):39-45. [CrossRef] [PubMed]
 
American College of Chest Physicians. Clinical indications for noninvasive positive pressure ventilation in chronic respiratory failure due to restrictive lung disease, COPD, and nocturnal hypoventilation—a consensus conference report. Chest. 1999;116(2):521-534. [CrossRef] [PubMed]
 
Manaker S, Pohlig C., eds. Coding for Chest Medicine 2013. Pulmonary, Critical Care, Sleep.16th ed. Northbrook, IL: American College of Chest Physicians; 2013.
 
Medicare Coverage Database. Centers for Medicare and Medicaid Services website. http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?. Accessed April 2, 2013.
 
Collop NA, Anderson WM, Boehlecke B, et al; Portable Monitoring Task Force of the American Academy of Sleep Medicine. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. J Clin Sleep Med. 2007;3(7):737-747. [PubMed]
 
US Department of Health and Human Services. DMEPOS competitive bid. Centers for Medicare and Medicaid Services website. http://www.cms.hhs.gov/DMEPOSCompetitiveBid/. Accessed April 2, 2013.
 
DMEPOS competitive bidding. Centers for Medicare and Medicaid Services website. http://dmecompetitivebid.com/palmetto/cbis.nsf/DocsCat/Homehttp://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSCompetitiveBid/MSAs_and_CBAs.html. Accessed November 11, 2013.
 
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Details for title: proposed policy and payment changes to the Medicare physician fee schedule for calendar year 2014. Centers for Medicare and Medicaid Services website. http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2013-Fact-Sheets-Items/2013-07-08.html. Accessed July 15, 2013.
 

Figures

Tables

Table Graphic Jump Location
Table 1 — Durable Medical Equipment Medicare Administrative Contractors

Data from Manaker and Pohlig.25 Ph = phone.

Table Graphic Jump Location
Table 2 —Initial Reimbursement Coverage Criteria for Respiratory Assist Devices

ABG = arterial blood gas; AHI = apnea-hypopnea index; PAP = positive airway pressure; PSG = polysomnogram; RDI = respiratory disturbance index; Spo2 = oxygen saturation as measured by pulse oximetry.

a 

Includes out-of-center sleep testing and home sleep testing.

b 

The treating physician is required to address and document interface fit and comfort and CPAP pressure settings including a trial and failure of lower settings to adequately control symptoms, improve sleep quality, or reduce AHI/RDI to acceptable levels before determining CPAP ineffective. During the initial 3-mo trial, substitution to an E0470 does not require a new initial face-to-face clinical evaluation or a new sleep test. Switching to an E0470 after > 3 mo of CPAP use requires a new face-to-face clinical evaluation but not a new sleep test.

Table Graphic Jump Location
Table 3 —Health-care Common Procedure Coding System Codes for Home Noninvasive Ventilation Equipment

Data from Manaker and Pohlig.25 HCPCS = Healthcare Common Procedure Coding System. See Table 2 legend for expansion of other abbreviation.

References

King AC. Long-term home mechanical ventilation in the United States. Respir Care. 2012;57(6):921-930. [CrossRef] [PubMed]
 
Finder JD, Birnkrant D, Carl J, et al; American Thoracic Society. Respiratory care of the patient with Duchenne muscular dystrophy: ATS consensus statement. Am J Respir Crit Care Med. 2004;170(4):456-465. [CrossRef] [PubMed]
 
Miller RG, Jackson CE, Kasarskis EJ, et al; Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter update: the care of the patient with amyotrophic lateral sclerosis: drug, nutritional, and respiratory therapies (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2009;73(15):1218-1226. [CrossRef] [PubMed]
 
Aurora RN, Chowdhuri S, Ramar K, et al. The treatment of central sleep apnea syndromes in adults: practice parameters with an evidence-based literature review and meta-analyses. Sleep. 2012;35(1):17-40. [PubMed]
 
Sharma BK, Bakker JP, McSharry DG, Desai AS, Javaheri S, Malhotra A. Adaptive servoventilation for treatment of sleep-disordered breathing in heart failure: a systematic review and meta-analysis. Chest. 2012;142(5):1211-1221. [CrossRef] [PubMed]
 
Morgenthaler TI, Gay PC, Gordon N, Brown LK. Adaptive servoventilation versus noninvasive positive pressure ventilation for central, mixed, and complex sleep apnea syndromes. Sleep. 2007;30(4):468-475. [PubMed]
 
Allam JS, Olson EJ, Gay PC, Morgenthaler TI. Efficacy of adaptive servoventilation in treatment of complex and central sleep apnea syndromes. Chest. 2007;132(6):1839-1846. [CrossRef] [PubMed]
 
Hess D. Positive pressure ventilators.. In:Elliott M, Nava S, Schonhofer B., eds. Non-invasive Ventilation and Weaning: Principles and Practice. London, England: Edward Arnold Publishers Ltd; 2010:13-24.
 
Bourke SC, Tomlinson M, Williams TL, Bullock RE, Shaw PJ, Gibson GJ. Effects of non-invasive ventilation on survival and quality of life in patients with amyotrophic lateral sclerosis: a randomised controlled trial. Lancet Neurol. 2006;5(2):140-147. [CrossRef] [PubMed]
 
Bach JR, Martinez D. Duchenne muscular dystrophy: continuous noninvasive ventilatory support prolongs survival. Respir Care. 2011;56(6):744-750. [CrossRef] [PubMed]
 
Simonds AK, Muntoni F, Heather S, Fielding S. Impact of nasal ventilation on survival in hypercapnic Duchenne muscular dystrophy. Thorax. 1998;53(11):949-952. [CrossRef] [PubMed]
 
Annane D, Orlikowski D, Chevret S, Chevrolet JC, Raphaël JC. Nocturnal mechanical ventilation for chronic hypoventilation in patients with neuromuscular and chest wall disorders. Cochrane Database Syst Rev. 2007;;(4):CD001941.
 
Gustafson T, Franklin KA, Midgren B, Pehrsson K, Ranstam J, Ström K. Survival of patients with kyphoscoliosis receiving mechanical ventilation or oxygen at home. Chest. 2006;130(6):1828-1833. [CrossRef] [PubMed]
 
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