Complex respiratory non invasive ventilation NIV expectations

DME provider requirements for NIV patients: what to submit with a new order, delivery and setup standards, member transition documentation, ongoing management, and resupply.

New orders

Patient and prescriber information

Patient demographics, patient contact information, prescriber contact information, hospital admission and discharge data, specialist contact information, and next planned doctor visits.

Standard written order

Include a complete Standard Written Order (SWO) specifying settings and equipment type, consistent with the billing requirements in the PDAC Correct Billing and Coding of Ventilators guidance for E0466, E0467, or E0468.

Qualifying documentation

• Ordered settings demonstrating the need for NIV
• History and physical, medical history, or medical summary document
• Evidence of prior therapies (optional)
• Certificate of Medical Necessity, or an explanation of need
• Qualifying diagnosis
• Qualifying testing for that diagnosis

Qualifying testing: COPD with chronic respiratory failure

All three must be met:

• Arterial blood gas PaCO2, taken while awake and breathing the patient’s prescribed FIO2, is greater than or equal to 52 mm Hg
• Sleep oximetry shows oxygen saturation at or below 88% for a cumulative 5 minutes or more of nocturnal recording time, with a minimum recording time of 2 hours, done while breathing oxygen at 2 LPM or the patient’s prescribed FIO2, whichever is higher
• Sleep apnea has been considered and ruled out

Qualifying testing: restrictive thoracic disorder, including obesity hypoventilation syndrome

Either of the first two, and COPD must not contribute significantly to the patient’s pulmonary limitations:

• Arterial blood gas PaCO2, taken while awake and breathing the patient’s prescribed FIO2, is greater than or equal to 45 mm Hg, or
• Sleep oximetry shows oxygen saturation at or below 88% for 5 minutes or more of nocturnal recording time, with a minimum recording time of 2 hours, done while breathing the patient’s prescribed FIO2
• For neuromuscular disease only, either maximal inspiratory pressure below 60 cm H2O, or forced vital capacity below 50% predicted

If an order for a respiratory assist device (RAD) arrives at the same time as the NIV order, submit it for qualification while the prior authorization is pending.

Delivery and setup

• Complete all initial equipment setup training, all setup documentation, and obtain patient signatures.
• Perform patient education and explain the device compliance requirements.
• Confirm ventilator and equipment settings match the prescriber’s orders.
• Follow up the next day, virtually or in person, then daily for one week after setup.

Supplies to provide at setup

• Correct interface for the patient
• Ventilator circuit, tubing, and filters
• Humidification, if applicable
• Ambu bag

Setup documentation

Complete documents in the Synapse Health Delivery portal. Anything not completed there must be uploaded within 2 business days of setup. All documents require patient signature. Documentation includes, but is not limited to:

• Home safety assessment
• Plan of care
• Ventilator flow sheet, including all settings
• Patient education and training confirmation, with signed training checklists for all equipment
• Itemized delivery sales order with all equipment serial numbers

Training requirements

• Schedule equipment training at the hospital, in the home, or a combination of both, and deliver equipment to the training location.
• A licensed respiratory therapist trains caregivers on all equipment until they demonstrate knowledge of use and care.
• Complete and sign caregiver competency checklists in full for every piece of equipment.
• Provide contacts for questions, malfunctions, supplies, and after-hours support.
• Communicate any barrier to patient or caregiver education to Synapse Health, the prescriber, and the case manager so a resolution plan can be put in place.

Tag Synapse Health in the cloud platform

Tag Synapse Health as part of the patient’s care team in the ventilator cloud platform so we have real-time access to data for clinical monitoring and compliance tracking. Platforms include:

• ResMed AirView
• React Connect
• Respironics Care Orchestrator
• BREAS EveryWare
• Movair Prisma Cloud

Communicate any delay or issue with delivery or setup to Synapse Health promptly.

Member transition patients

For patients transitioning to Synapse Health, provide everything listed under new orders, plus documentation from the previous 90 days:

• Utilization data
• Ventilator flow sheet
• Most current plan of care
• Most current orders

Tag Synapse Health in the patient’s ventilator cloud platform as described above.

Ongoing management

Maintenance documentation standards

Maintenance and service logs must record:

• Ventilator make, model, and serial number
• Date of maintenance or service
• Description of maintenance performed
• Name or identifier of the technician who performed the service
• Verification that the maintenance aligns with manufacturer-recommended intervals

Compliance, adherence, and emergency management

• Monitor adherence daily.
• Reach out to patients individually for troubleshooting and education to improve adherence.
• Follow up on physician visits.
• Notify Synapse Health within 2 business days when a patient is noncompliant or nonresponsive, has a change in status, or needs a device returned.
• Provide 24/7 emergency support for ventilator-dependent patients, covering device troubleshooting, servicing, and replacement.
• Establish and manage the patient’s emergency preparedness plan, including notifications to local emergency services.
• Provide loaner equipment during servicing or replacement.

Patient visits

• Conduct routine in-home evaluations for therapy adjustments, at the frequency and in the medium required by regulation.
• Conduct visits at a minimum of every 90 days, based on state requirements and patient acuity.
• Submit all visit notes to Synapse Health within 2 business days of the completed visit.
• If a visit is missed, notify Synapse Health using the Missed Patient Visit form by fax or email.

What to document at every visit

• Patient name and a second patient identifier
• Date of visit
• Respiratory therapist name and credentials
• Visit modality, virtual or in person
• Ventilator type, model, and serial number
• Ventilator settings including mode, parameters, comfort settings, and alarm settings
• Date and hours of the last preventative maintenance, and when the next is due
• Usage hours, whether the patient is compliant (more than 4 hours per night daily), and leak value in L/min
• Power supply and battery checked
• Alarms tested and functional
• Circuits intact
• Filters checked and replaced
• Ambu bag present at the bedside
• Humidification: water chamber filled appropriately, no contamination or excessive condensation
• Interface assessment: mask fits properly with no excessive leaks, and no skin breakdown or pressure sores
• Patient or caregiver expresses understanding of the plan of care, proper equipment use, emergency procedures and troubleshooting, alarm recognition and response, and cleaning and maintenance. Address any barriers.
• Clinical assessments and observations
• Resupply recommendations or changes
• Physician orders reviewed and up to date
• Supply replacement schedule reviewed
• Next visit due

Resupply

Mask refit

• When a patient requests a mask refit, notify Synapse Health with the reason and your suggested replacement.
• Use the new sales order from Synapse Health and ship the new mask directly to the patient.
• Upload a copy to the delivery ticket.

Routine resupply

Change all supplies related to ventilator use at least monthly. More frequent changes may be needed depending on patient usage, environment, and need.

Questions and escalation

For urgent patient issues, call Synapse Health immediately. For non-urgent questions about visits, documentation, or compliance, email the clinical team and expect a response within 3 business days. If Synapse Health identifies a compliance or clinical concern, you will receive a formal inquiry through the Delivery portal or by email with a request for response within 3 business days.