Qualifications for Home Respiratory Equipment by AmnaKhan

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									Qualifications for Home Respiratory Equipment

What Every RT Needs To Know
Paula D. Estridge, RT

Objectives/Performance Measures
Understand the primary components of qualifying home respiratory equipment  Identify the primary home respiratory equipment  Identify the primary insurance requirements to be met for each type of home respiratory equipment  Distinguish between the different testing required for each type of home respiratory equipment
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Paula D. Estridge, RT

Vocabulary
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CPAP- Continuous Positive Airway Pressure Device BiPAP- Bi-level Positive Airway Pressure Device S-Spontaneous Rate Only ST-Spontaneous and Timed Rate Unit Dose Medication- Aerosolized Breathing Medications (Albuterol, Atrovent, Steriods, etc.) Oxygen- Home Oxygen Equipment including Concentrators, Liquid Oxygen Systems and Portable Gas and Liquid Oxygen Systems Restrictive Thoracic Disorders- Tuberculosis, Polio, Cystic Fibrosis, Obesity with Hypoventilation, ALS, Multiple Sclerosis, Myotonic Dystrophy, Restrictive Lung Disease, Diaphragm Paralysis, Kyphoscoliosis, Chest Wall Deformity, Spinal Cord Injury

Paula D. Estridge, RT

Unit Dose Medications
The following diagnoses ONLY: 1. 491.0 through 505 Obstructive lung disease 2. 277.00 Cystic Fibrosis 3. 042 HIV 4. 786.4 Abnormal Sputum  The physician must have considered metered dose inhalers (MDI) prior to prescribing nebulizer treatments.  Most Common Diagnosis 1. COPD (496) 2. Emphysema (492.8) 3. Asthma (493.90) 4. Chronic Bronchitis (491.0)
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Paula D. Estridge, RT

Oxygen
If an inpatient hospital stay, the reported test must be done no earlier than 2 days prior to hospital discharge date  If not inpatient, the reported test must be done within 30 days of the date of order while the patient is in a chronic stable state  Alternative treatment measures have been tried or considered and deemed ineffective
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Paula D. Estridge, RT

Oxygen Continued
Group I
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An ABG PO2 </= 55 mmHg or an SaO2 </= 88% taken at rest (awake) and breathing room air, or An ABG PO2 </= 55 mmHg or an SaO2 </= 88%, for at least 5 cumulative minutes, taken during sleep and breathing room air, for a patient that doesn’t meet the requirements while they are awake A decrease in the ABG PO2 of more than 10 mmHg, or a decrease in the SaO2 of more than 5 %, for at least 5 minutes taken during sleep associated with symptoms or signs reasonable attributable to hypoxemia (e. g., cor pulmonale, “P” pulmonale on ECG, documented pulmonary hypertension and erythrocytosis), or An ABG PO2 </= 55 mmHg or an SaO2 </= 88%, taken during exercise for a patient who demonstrates an PO2 >/= 56 mmHg or an SaO2 >/= 89% during the day while at rest.

Paula D. Estridge, RT

Oxygen Continued
Group II
Criteria include the presence of (a) a PO2 of 56-59 mmHg or an SaO2 of 89% at rest (awake), during sleep for at least 5 cumulative minutes, or during exercise (as described in Group I) and any of the following:
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Dependent edema suggesting congestive heart failure, or Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or “P” pulmonale on ECG (P wave greater than 3 mm in standard leads II, III, or AVF), or Erythrocythemia with a hematocrit greater than 56% LIMITED TO THREE MONTHS OR THE PHYSICIAN SPECIFIED LENGTH OF NEED, WHICHEVER IS SHORTER THEN NEW TESTING WILL BE REQUIRED TO CONTINUE COVERAGE.

Paula D. Estridge, RT

OXYGEN TESTING TIPS
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DO RESTING, ON ROOM AIR PO2 OR SaO2 FIRST (</= 55 mmHg or 88%) (OR 56-59mmHg or SaO2 of 89%) (STOP HERE IF MEETS CRITERIA) DO EXERCISE PO2 OR SaO2 NEXT, ON ROOM AIR, IF ABOVE CRITERIA NOT MET. IF MEETS REQUIREMENTS, THEY WILL PAY FOR PORTABLE OXYGEN SYSTEM ONLY (MUST DO NEXT STEP IF QUALIFIES ON THIS TEST) THEN PLACE ON OXYGEN LPM TO BE PRESCRIBED AND RETEST TO SHOW THAT IT IS THE RIGHT AMOUNT FOR THE PATIENT (WILL HAVE 3 TEST RESULTS BY THIS TIME) IF CAN NOT GET TO QUALIFY WITH THE ABOVE STEPS, DO OVERNIGHT OXIMETRY ON THE PATIENT. IF THE PATIENT HAS A SaO2 </= 88% FOR A CUMULATIVE 5 MINUTES, THEY QUALIFY FOR NOCTURNAL OXYGEN ONLY.

Paula D. Estridge, RT

CPAP Device
The patient must:  Have an AHI (apnea-hypopnea index) of greater than or equal to 15 events per hour OR  Have an AHI of 5-14 events per hour with documentation of one of the following:
1. Excessive daytime sleepiness 2. Impaired cognition 3. Mood disorders 4. Insomnia 5. Hypertension 6. Ischemic heart disease 7. History of stroke
Paula D. Estridge, RT

CPAP Device Continued:
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The AHI (apnea-hypopnea index) is equal to the average number of episodes of apnea and hypopneas per hour and must be based on a minimum of 2 hours of sleep recorded by polysomnography using actual recorded hours of sleep. The AHI may not be extrapolated or projected. A complete copy of the polysomnogram must accompany the prescription to the home medical equipment provider.

Paula D. Estridge, RT

Respiratory Assist Devices
BiPAP S/ BiPAP ST
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OSA (Obstructive Sleep Apnea) BiPAP S only

1. A polysomnogram has established the diagnosis of OSA as the predominant cause of sleep associated hypoventilation and 2. Prior to initiating therapy, a CPAP device has been tried and proved ineffective.
Paula D. Estridge, RT

Respiratory Assist Devices Continued:
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For CSA (Central Sleep Apnea) BiPAP S or BiPAP ST
1. The diagnosis of CSA and the exclusion of OSA as the predominant cause of sleep associated hypoventilation, and 2. If OSA is a component, the CPAP has been ruled out as effective therapy for the patient, and 3. Sleep oximetry with SaO2 of </= 88% for at least five continuous minutes, done while the patient breathing their usual FiO2, and 4. Improvement noted on the settings the patient will be using at home on their usual FiO2 and documented.

Paula D. Estridge, RT

Respiratory Assist Devices Continued:
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Restrictive Thoracic Diseases BiPAP S or BiPAP ST

1. There is documentation of progressive neuromuscular disease or severe thoracic cage abnormality, and 2. One of the following conditions are met:
A: An ABG done while awake and breathing their usual FiO2 is >/= 45 mmHg, or B: Sleep oximetry documents SaO2 </= 88% for at least five continuous minutes, done on usual FiO2, or C: For progressive neuromuscular patients only, maximal inspiratory pressure is </= 60 cmH2O or forced vital capacity is < 50% of predicted, and

3. COPD does not contribute significantly to the patient’s pulmonary limitation
Paula D. Estridge, RT

Respiratory Assist Devices Continued:  COPD (BiPAP S initially, with possible upgrade
to BiPAP ST after 60 days)
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BiPAP S
1. An ABG PaCO2, done while awake and breathing the patient’s usual FiO2, is >/= 52 mmHg, and 2. Sleep oximetry documents SaO2 </= 88% for at least five continuous minutes, done while breathing either 2 lpm or the patient’s usual FiO2, whichever is higher, and 3. Prior to initiating therapy, OSA and treatment with CPAP has been considered and ruled out by the physician.

Paula D. Estridge, RT

Respiratory Assist Device for COPD Patients after at least 60 days of BiPAP S therapy needing BiPAP ST
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An ABG PaCO2, repeated no sooner than 61 days from the start of therapy on the BiPAP S, done while awake and breathing the patient’s usual FiO2 still remains >/= 52 mmHg, and Sleep oximetry, repeated no sooner than 61 days from the start of therapy on the BiPAP S, while breathing on the BiPAP S, documents SaO2 </= 88% for at least five continuous minutes, done while breathing oxygen at 2lpm or the patient’s FiO2, whichever is higher, and The patient must be evaluated by the physician no sooner than 61 days from the start of therapy on the BiPAP S and determined to have been compliantly using the device (an average of 4 hours per 24-hour period) and NOT benefiting from its use, and The patient must confirm compliant use of the BiPAP S device (through completion of the Beneficiary Statement) no sooner than 61 days from the start of therapy on a BiPAP S

Paula D. Estridge, RT

For Continuing Coverage of a BiPAP After the First Three Months of Therapy, Regardless of Diagnosis:
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The patient must be re-evaluated by the physician within 61-90 days from the start of therapy and determined (through the completion of the Statement of the Treating Physician) to be compliantly using the device (an average of 4 hours per 24-hour period) and benefiting from its use, and The patient must confirm compliant use of the device (through completion of the Beneficiary Statement) no sooner than 61 days from the start of therapy.

Paula D. Estridge, RT


								
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