Challenges of Noninvasive Positive Pressure Ventilation (NPPV)

Clinicians treating patients with chronic respiratory insufficiency are challenged by both the practice guidelines and the reimbursement criteria. The current state of affairs may well change in 2010, but the present issues are described briefly below. The NAMDRC Consensus Conference took place in February 1998 and the “Clinical Indications for Noninvasive Positive Pressure Ventilation in Chronic Respiratory Failure” document was later published in CHEST in 1999. The conference was a unique format in that it included academic clinicians, Centers for Medicare and Medicaid Services (CMS) officials, and industry representatives, although only the clinicians provided writing for the publication. The document contained limited evidence-based medicine, but it did lead to the CMS criteria for reimbursement to guide future practice.

Ultimately, several categories of guidelines and reimbursement have been established. The way to approach the categories is to realize they are first guided by the primary diagnosis and not by the subsequent criteria. It is also important to realize that patients who require or are allowed access to a backup rate (E0471) obtain nearly twice the monthly reimbursement than those not using a backup rate (E0470). Therefore, the use of the E0471 is more restricted.

These disease categories require the clinician to focus on sleep early in the assessment of the patient. It is necessary to decide on the need and urgency of a sleep study, as well as the design of the sleep study in order to effectively demonstrate the criteria and good response to the respiratory assist device (RAD).

The bottom line is that one needs to know the rules to play the game, but playing the game is not gaming the system—it is simply necessary. Ironically, if the treating clinician determines that the RAD criteria cannot be met, but nocturnal NPPV support is necessary, he or she can always prescribe a portable home ventilator (E0450), with a diagnosis of “hypoxic or hypercapnic respiratory failure” and use a volumetargeted ventilator with only a blood gas demonstrating this diagnosis. Although pulmonologists often prescribe this equipment, sleep specialists are more typically familiar with the indications and reimbursement criteria and are readily available to help.

Dr. Peter Gay, FCCP
NetWork Chair