Attention: DME Providers PA and Claim Information for DME codes E0450, E0463 and E0465

Per CMS mandate, DME HCPCS codes E0450- Volume control ventilator, without pressure support mode, may include pressure control mode, used with invasive interface (e.g. tracheostomy tube) and E0463 –Pressure support ventilator with volume control mode, may include pressure support mode, used with invasive interface (e.g. tracheostomy tube) are being end dated with an effective date of December 31, 2015. The code to replace these end dated codes is E0465 – Home ventilator, any type, used with invasive interface (e.g. tracheostomy tube) with an effective date of January 1, 2016.

This change was implemented in NCTracks on December 22, 2015, and affects prior approval and claims for these codes.

Prior Approval -

DME prior approval (PA) requests for Home Ventilators that are now being submitted to NCTracks with the end dated codes that span into 2016 cannot be processed.

To obtain prior approval for a Home Ventilator beginning in 2015 and continuing into 2016, the DME provider needs to submit two separate prior approval requests:

  • One PA request using the old HCPCS codes for dates up to and including December 31, 2015, and
  • One PA request using the new HCPCS code for dates of service beginning January 1, 2016, and forward.

The old and new HCPCS codes for Home Ventilators cannot be submitted on the same PA or the request will deny.

DME Home Ventilator prior approval requests already in the system for dates that span from 2015 into 2016 are being researched and more information is forthcoming.

PA requests submitted for an effective date of January 1, 2016, or forward, should use code E0465.

Claims –

Claims that span beyond December 31, 2015 date of service will need to be split when filed. A split claim is actually two claims: one with codes for services provided prior to December 31, 2015 (E0450 and E0463) and another claim with E0465 for services provided on or after January 1, 2016. There must be a corresponding prior approval for each claim.