Effective for dates of service on or after April 1, 2025, the rental of dual-function home ventilators (procedure code E0468) is a benefit of Texas Medicaid.
Note: The Texas Health and Human Services Commission (HHSC) must present new proposed benefits at a rate hearing to receive public comment on reimbursement rates. After the rate hearing, HHSC must approve the expenditures before Texas Medicaid can adopt the rates. TMHP will notify providers in a future article if a proposed reimbursement rate will change or a procedure code will not be reimbursed because the expenditures were not approved.
Prior Authorization:
The client’s treating physician or allowed practitioner must request prior authorization for the rental of a dual-function home ventilator (procedure code E0468). The client must meet the medical necessity criteria for both a mechanical ventilator and a cough augmentation device.
Providers can find more information about medical necessity and prior authorization requirements in the following subsections of the current Texas Medicaid Provider Procedures Manual (TMPPM), Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook:
- Subsections 2.2.23.9, “Mechanical Ventilation,” and 2.2.23.9.1, “Prior Authorization,” provide information about requirements for mechanical ventilation.
- Subsection 2.2.23.11.1, “Prior Authorization,” provides information about requirements for a cough augmentation device.
To request prior authorization of procedure code E0468, providers must submit the Home Health Services (Title XIX) DME/Medical Supplies Prescribing Provider Order Form.
Note: Providers may include documentation of medical necessity on the form or submit it as supplemental documentation.
In addition to the Title XIX form, providers may submit the Texas Medicaid Prior Authorization Request for Secretion and Mucus Clearance Devices – Initial Request form to document medical necessity for a cough augmentation device.
Related Procedure Codes: Effective for dates of service on or after July 1, 2025, TMHP will deny claims for the following procedure codes if they are submitted by any provider in the same month as procedure code E0468:
Providers are encouraged to share this information with their staff. If you have any questions about this notice, please email Provider Relations at ProviderRelations@cfhp.com or call 210-358-6030. You can also contact your Provider Relations Representative directly.
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