Ventilators

Affected Providers

Physicians, non-physician practitioners, and suppliers who bill for ventilators.

Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for ventilators is 13.3%, with a projected improper payment amount of $63.5 million.

You must meet the provisions in National Coverage Determination (NCD): Durable Medical Equipment Reference List (280.1).

Denial Reasons

Insufficient documentation accounted for 66.5% of improper payments for ventilators during the 2024 reporting period, while no documentation (4.2%) and other errors (29.3%) also caused improper payments. “Other” errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.

Preventing Denials

We cover ventilators for treating a patient who has:

• Neuromuscular disease
• Diabetes
• Thoracic restrictive disease
• Chronic respiratory failure resulting from chronic obstructive pulmonary disease (includes both positive and negative pressure types)

Documentation Requirements

To justify payment, you must meet specific requirements when ordering DMEPOS.