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By Carrie Nienberg, RN, CPC, Director of Clinical Operations

Effective January 1st, 2019, E0467 can be billed to Medicare for reimbursement. An E0467 is defined as "a home ventilator, multi-function respiratory device, also performs any or all of the additional functions of oxygen concentration, drug nebulization, aspiration and cough stimulation, includes all accessories, components and supplies for all functions."

This device is in the frequent and substantial servicing payment category. To meet medical necessity, in addition to meeting coverage criteria for a ventilator, the beneficiary must meet coverage criteria for at least one of the other four additional functions (oxygen concentrator, cough stimulator, suction pump and nebulizer).

Because this multi-function ventilator replaces multiple stand-alone devices, Change Request 10854 (CR10854) instructs the MAC’s to deny claims that are submitted on the same claim or that overlap any dates of service for the new multi-function ventilator for same/similar items if furnished on or after the date that the multi-function ventilator is furnished.

The following HCPCS are integrated into the multi-function ventilator or represent similar equipment used for the same purpose and would be denied if billed in conjunction with the new multi-function ventilator:

  • Oxygen and oxygen equipment (E0424, E0431, E0433, E0434, E0439, E0441, E0442, E0443, E0444, E1390, E1391, E1392, E1405, E1406 and K0738)
  • Nebulizers and related accessories (E0565, E0570, E0572, E0585, E4619, A7003, A7004, A7005, A7006, A7007, A7012, A7013, A7014, A7015, A7017, A7525 and E1372)
  • Aspirator and related accessories (E0600, A4216, A4217, A4605, A4624, A4628, A7000, A7001, A7002 and A7047)
  • Cough Stimulator, High Frequency Chest Wall Oscillation, Oscillatory Positive Expiratory Pressure and related accessories (E0482, A7020, E0483, A7025, A7026 and E0484)
  • CPAP, RAD and related accessories (E0601, E0470, E0471, E0472, A4604, A7027, A7028, A7029, A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7044, A7045, A7046, E0561 and E0562)
  • Oral appliance (E0486)
  • Ventilators (E0465 and E0466)

Want to feel confident that the ventilators you are providing meet coverage criteria? Sign up for our ventilator prescreen program.

Before you put out the equipment, let our clinical staff review your documentation to ensure the ventilator meets coverage criteria. Our clinicians will review your documentation and provide you with an “approved” or “denied” status, along with recommendations for your referral source. Get your documentation right before you bill the claim to Medicare, and rest easy knowing you are protected should those claims be audited in the future.

Contact us for more information!

For CMS direction on billing, including repair and labor and denial messages, review MM10854.