Non-Invasive ventilators (NIV) have been circling back with questions on documentation requirements. This means it’s time to review the requirements needed for NIV coverage particularly since there is not a medical policy (LCD).
Here are helpful tips regarding ventilator coverage:
- Generally covered for treatment of neuromuscular disorders, thoracic restrictive diseases, or chronic respiratory failure secondary to COPD.
- Make sure the least costly alternative has been considered or tried and ruled out. Why is a BIPAP insufficient or will not work for the patient? What does the NIV have that will work for the patient? *This is very important information to that must be documented in the patient’s medical record.
- Tell the story of the patient (paint the picture). The only information a reviewer has on the patient is the information provided within the documentation. Make sure it is justifying the medical need for the NIV being ordered.
It’s very important to be proactive by reviewing patients files to make the necessary information has been obtained. Does the medical record state that BiPAP has been tried or considered and ruled out? If the medical record states something like, “patient is on BiPAP and seems to be doing well” and then an NIV is ordered, you will get a denial. And the medical record should not state “BiPAP was considered and ruled out”. There needs to be more detailed information rather than a generic statement.
Recently, there has been conversation that Medicare has not been auditing on ventilators, or has pulled back. I Documentation is KEY when dealing with any home medical equipment. A diagnosis alone is not enough information to support the need. As mentioned earlier, paint the picture, tell the story. n September, there was a report released by the OIG regarding NIVs. (report attached here) The study reported that Medicare paid 85 times more on NIVs in 2015 compared to 2009. And in 2015, the most common diagnosis was chronic respiratory failure, it increased to 85% compared to 2009 it was only at 29%. The neuromuscular disorders were the most common in 2009 at 57% and decreased to 7% in 2015. The study also mentioned that the NIV was paid inappropriately for certain diagnosis such as OSA. While the top 3 companies are known, this does not mean you company is off the hook.
What does this mean? Post payment audits.
Do not fall into a trap. Documentation is key when dealing with any home medical equipment, and especially when dealing with NIVs. A diagnosis alone is not enough information to support the need. As mentioned earlier, paint the picture, tell the story, of the patient.
For further questions or comments, please contact:
Ronda Buhrmester, CRT, CFm,