CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Multi-function Home Ventilator — Rental Reimbursement and Bundled Accessory Rules

Defines Blue Cross Blue Shield of Rhode Island payment rules for rental reimbursement when a multi-function home ventilator (device that integrates ventilator plus other therapies) is billed, and lists HCPCS/CPT codes considered not separately reimbursed during the ventilator rental period. Affects claims for BlueCHiP for Medicare and Commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMulti-function Home Ventilator — Rental Reimbursement and Bundled Accessory Rules

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2020

Next Review DateN/A

Key ActionDo not separately reimburse specified stand-alone devices and accessories billed concurrently during rental of a multi-function home ventilator (E0467RR).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

monthlypayment basis under frequent and substantial servicing DME category

E0467RRprimary HCPCS code referenced

multiplecodes not separately reimbursed with E0467RR

variesbenefits vary by contract

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Reimbursement and bundled accessory rules

Covered when ALL of the following apply:

A claim is received for the rental of a multi-function home ventilator billed with HCPCS E0467RR (Home ventilator, multi-function respiratory device).

During the rental period, BlueCHiP for Medicare and Commercial Products will not separately reimburse the specified stand‑alone devices and related accessories when billed with the multi‑function ventilator rental.

Benefits and eligibility for durable medical equipment vary by group and contract; refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable coverage determinations.

Not separately reimbursed items (examples)

Ventilators
Oxygen and oxygen equipment
Nebulizers and related accessories
Aspirator and related accessories
Cough stimulator devices and related components
High Frequency Chest Wall Oscillation (HFCWO) devices and related accessories
Oscillatory positive expiratory pressure devices (e.g., Flutter, Acapella)
PAP and RAD devices and related accessories
Oral appliances

Representative HCPCS/CPT codes considered not separately reimbursed when billed with E0467RR (not exhaustive)

A4216 — Sterile water; saline and/or dextrose, diluent/flush; 10 ml
A4217 — Sterile water/saline, 500 ml
A4604 — Tubing with integrated heating element for use with positive airway pressure device
A7000–A7017 series — suction canisters, tubing, administration sets, nebulizers, filters, aerosol masks, and related nebulizer accessories (see coding list)
A7025, A7026 — HFCWO vest replacement and HFCWO hose
(See full coding section for the complete list of codes not separately reimbursed with E0467RR)

Prior authorization: Not applicable per this policy document.

HCPCS / CPT Codes and Payment Basis

Codes not separately reimbursed with multi-function ventilatormixedNot Covered

E0467RR	Home ventilator, multi-function respiratory device; includes all accessories, components and supplies for all functions
A4216	Sterile water; saline and/or dextrose, diluent/ flush; 10 ml
A4217	Sterile water/ saline, 500 ml
A4604	Tubing with integrated heating element for use with positive airway pressure device
A4605	Tracheal suction catheter, closed system, each
A4619	Face tent
A4624	Tracheal suction catheter, any type other than closed system, each
A4628	Oropharyngeal suction catheter, each
A7000	Canister, disposable, used with suction pump, each
A7001	Canister, nondisposable, used with suction pump, each

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Rental payment basis — frequent and substantial servicing DME (monthly rental)

Payment basisOne monthly rental payment under the frequent and substantial servicing DME payment category paid monthly until medical necessity ends

Includes accessoriesMonthly payment includes payment for all related accessories necessary for effective use of the equipment

Regulatory referenceCMS payment rule added at 42 CFR 414.222 addressing multi-function ventilator payment

ApplicabilityApplies when device is billed as a rental (E0467RR) and replaces multiple stand‑alone devices such as oxygen concentrator, nebulizer, aspirator, cough stimulator

Key Definitions

Multi‑function home ventilator — device description

DefinitionA ventilator that integrates multiple therapies (for example: oxygen concentration, nebulization, aspiration, cough stimulation) into a single device and may replace multiple stand‑alone devices

Billing identifierWhen billed as a rental, primary HCPCS code referenced is E0467RR (Home ventilator, multi‑function respiratory device)

Scope of functionsPerforms any or all additional functions of oxygen concentration, nebulization, aspiration and cough stimulation and includes all accessories, components and supplies for all functions

Payment implicationWhen rented, related stand‑alone devices and accessories billed concurrently are considered not separately reimbursed during the rental period