Rule 5160-10-22 | DMEPOS: ventilators.
(A) Condition of provider participation. A provider of in-home use ventilators needs to have available a licensed respiratory care professional (LRCP) twenty-four hours a day to provide respiratory care, technical support, and clinical ventilator services and to perform emergency servicing of equipment on two-hour notice.
(B) Coverage.
(1) Separate payment may be made for a ventilator furnished to a resident of a long-term care facility (LTCF).
(2) Payment may be made for a ventilator on a rental basis only. The default certificate of medical necessity (CMN) form is the ODM 01902, "Certificate of Medical Necessity: Ventilators" (rev. 7/2021).
(3) For the rental of a primary ventilator, a CMN includes the following information:
(a) Diagnosis;
(b) Specification of the condition or conditions for which ventilatory support is needed;
(c) An estimated length of need;
(d) The continuity of ventilatory support needed (constant, during the day, at night, for sleep only);
(e) The ventilator type, mode, and settings or parameters;
(f) A list of other respiratory equipment in use; and
(g) If applicable, documentation showing that the individual is being weaned.
(4) For the rental of a secondary or back-up ventilator, the CMN includes appropriate attestation to at least one of the following statements:
(a) The individual cannot maintain spontaneous respiration for at least four hours;
(b) Because of regular activities outside the home such as school or outpatient therapy), the individual needs a second ventilator with a suitable power source; or
(c) The average emergency medical team response time to the individual's address is estimated to be more than two hours.
(5) A multi-function ventilator is an all-in-one device that also has the capability to perform the functions of other respiratory equipment such as an oxygen concentrator, a nebulizer, a suction device, or a cough-assist device. A device that may serve either as a ventilator or as a positive airway pressure device but not as both simultaneously is not a multi-function ventilator.
(a) Payment may be made for a multi-function ventilator only if at least one additional function ("ventilator plus one") is used.
(b) For each additional function, whether included when the unit is first dispensed or activated later, the appropriate CMN applies. A prescription is sufficient when no CMN is specified for a particular function.
(C) Constraints and and limitations.
(1) A ventilator with an invasive interface is covered only if it includes backup power capability and alarms indicating disconnection, high pressure, low pressure, and power loss.
(2) Rental of a ventilator includes the following items and services:
(a) Ventilator accessories, including inlet ventilator filters, permanent or reusable ventilator circuits, whisper swivels, exhalation ports, tracheostomy tube elbows, and circuit extensions and adapters;
(b) Accessories necessary for the oxygen and ventilator functions of a multi-function ventilator;
(c) A humidifier, either heated or unheated;
(d) Humidifier bacteria filters;
(e) Tubing to connect the humidifier to the ventilator;
(f) Evaluation of the individual's residence to ensure compatibility with the equipment and to forestall problems with its use; and
(g) Visits made at an appropriate frequency determined by a LRCP in consultation with the individual's prescribing practitioner, at least one visit during the first week, not less often than once per month for the first six months, and not less often than every sixty days thereafter.
(3) No separate payment is made to a provider for keeping a LRCP on call or for performing emergency servicing of equipment.
Last updated July 1, 2021 at 10:54 AM
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