It has become clear, over the last 10+ years, the critical importance of good airway clearance of secretions as respiratory muscles become weaker, particularly for people with neuromuscular diseases (but also for people with intrinsic lung disease as they become weaker). The importance of both the expiratory muscles as well as the inspiratory muscles needs attention. Effective assisted cough techniques should be taught early, certainly when peak cough flow (PCF) falls below 300 lpm. Both breath stacking, to increase inspiratory capacity, and assisted cough flow are needed. When manual methods are not sufficient, then the CoughAssist made by Phillips/Respironics (previously called the In-Exsufflator), should be used to ensure a good PCF. In the past reimbursement had been a barrier. Now CMS (Centers for Medicare & Medicaid Services) has created a new HCPCS code for Medicare to reimburse for the Cough Assist device when it is clinically appropriate. Most health plans and health insurance companies follow Medicare policies for those covered for medical equipment. The information below summarizes the details. Ventilator users and their caregivers should become familiar with this information.
With all best wishes,
Edward Anthony Oppenheimer, MD, FCCP
Pulmonary Medicine Los Angeles, California
Cough stimulating device: Medicare HCPCS code E0482
- Cough stimulating device, alternating positive and negative pressure.
- Effective date: January 1, 2002
- Medical necessity documentation is required.
- 13 months capped rental is covered.
The CoughAssist: This is a device that helps patients who cannot cough for themselves. It enhances or replaces a patient's natural removal of bronchial secretions. The noninvasive device simulates a natural coughing process and reduces the risk of airway damage and respiratory complications associated with more invasive procedures.
The CoughAssist assists patients in clearing secretions by gradually applying positive pressure to the airway to achieve a good inspiratory lung volume, and then cycling rapidly to negative pressure to achieve effective expiratory cough flow. This rapid shift in pressure, via a mask, mouthpiece, or artificial airway, produces a high expiratory flow rate from the lungs, which simulates a cough.
- Model CM-3000 cycles manually from positive to negative pressure.
- Model CA-3000 cycles automatically.
Phillips/Respironics now offers five different sizes of masks and a tracheostomy adapter. These part numbers are accessible at Respironics.
The CoughAssist is a revised model of the Emerson In-Exsufflator, based on the Cofflator (O.E.M Corporation). The CoughAssist (or In-Exsufflator) is a portable electric device which utilize a blower and a valve to alternately apply a positive and then a negative pressure to a patient's airway in order to assist the patient in clearing retained bronchopulmonary secretions. Air is delivered to and from the patient via a breathing circuit incorporating a flexible tube, a bacterial filter and either a facemask, a mouthpiece, or an adapter to a tracheostomy or endotracheal tube.
The CoughAssist is indicated for use by patients who are not only unable to cough, but also unable to clear secretions effectively using available manual cough assistive techniques. This patient population experiences reduced peak cough expiratory flow (PCF) resulting from high spinal cord injuries, neuromuscular deficits or severe fatigue associated with intrinsic lung disease.
Contraindications for the CoughAssist: history of bullous emphysema, susceptibility to pneumothorax or pneumomediastinum (lung barotrauma injury). People with cardiovascular instability should be cautious, and if the CoughAssist is used it should probably initially be used with professional observation at a medical center with at least oximetry monitoring of heart rate and oxygen saturation, before use in the home.
Published studies are available. Information available on the Internet includes the Respironics website.
Respironics has information and tips on their website; also your physician or equipment company can contact their reimbursement services staff (800-345-6443 or 800-659-9235).
"Helpful Hints" for filing a physician's statement of medical necessity to support coverage for the CoughAssist — (modified from Respironics):
- The respiratory-related diagnosis and resulting severity of respiratory muscle impairment should be documented. This should emphasize the weakness of cough and the decreased related pulmonary function, such as: a peak cough flow (PCF) that is equal to or below 300 lpm, and a reduced maximal expiratory force (MEF) equal to or less than 60 cm H2O. Any tendency to aspirate should also be documented as an important aggravating factor.
- The physician should consider the "least costly" effective alternative, and so state in the supporting letter
- The patient has tried several different methods to control and clear airway secretions; including inhalers, incentive spirometry, PEP mask therapy. without significant response. (include the methods tried by your patient)
- Since starting the CoughAssist the patient has had better control of his disease (i.e.: hospitalizations, emergency room visits, and other invasive procedures such as deep tracheal suctioning or bronchoscopy)." give details.
- Due to the prognosis, respiratory airway secretion problems and respiratory infections are expected and frequently result in major complications, hospitalizations or death unless controlled effectively.
Other Airway Clearance Devices
Some other airway clearance devices (these are not covered by this HCPCS code):
- Yankauer suction tube with a suction device: Effective for removing oral secretions and phlegm that is coughed up to the oral pharynx. Inexpensive.
- Resuscitator bag: Effective to assist with breath stacking, to increase maximum inspiratory capacity prior to a cough. Various manufacturers (such as Ambu bag). Alternatives to achieve breath stacking are: glossopharyngeal breathing (GPB), or the use of a volume ventilator. Inexpensive.
- Palm Cups Manual Percussors: Soft vinyl percussors for performing chest physiotherapy. Palm Cups are used to percuss the chest wall to mobilize the secretions within the bronchial tree. Primarily for patients with cystic fibrosis, chronic bronchitis, pneumonia, etc.... Probably not useful for people neuromuscular disease and respiratory muscle weakness. Inexpensive. DHD Healthcare, Wampsville, NY. Inexpensive.
- Mechanical Percussors: Made by various manufacturers. Often used together with postural drainage in 6-12 different PD positions. An effective cough is required to bring up the phlegm once it is loosened. They are of uncertain value for people with neuromuscular disease and respiratory muscle weakness. Inexpensive.
- Flutter device: Produces chest wall oscillation to loosen mucous secretion. Published evaluations are available regarding its use in cystic fibrosis. Probably not useful for people with neuromuscular disease and respiratory muscle weakness. Inexpensive. Axcan Scandipharm, Birmingham, Alabama. Inexpensive.
- The Vest Airway Clearance System: Produces high frequency chest wall oscillation to loosen mucous secretion. An effective cough is required to bring up the phlegm once it is loosened. This can help loosen secretions, which then have to be cleared from the airways (using an additional effective method) of people with neuromuscular disease and respiratory muscle weakness. Very expensive approx. $14,000. Advanced Respiratory, St. Paul, Minn.
- TheraPEP Positive Expiratory Pressure Therapy System: claims to be particularly effective in clearing secretions from small airways. An effective cough is required to bring up the phlegm once it is loosened. Of uncertain value for people neuromuscular disease and respiratory muscle weakness. Published studies are available. Inexpensive. DHD Healthcare, Wampsville, NY.
- PercussiveNEB: A high Frequency intrapulmonary percussive device for use in the removal of mucus from the lungs in patients with retained endobronchial secretions. Of uncertain value for people neuromuscular disease and respiratory muscle weakness. Inexpensive. VORTRAN Medical Technology 1, Inc., Sacramento, CA.
- Hayek Oscillator: Available only outside USA. Very expensive. Breasy Medical Equipment, Inc., London NW4, England.
- Quik-Coff: Not available for use in the USA. Designed to augment cough by electrical stimulation of the abdominal expiratory muscles in people with early spinal cord injury. Not marketed at this time and no longer on their website. B & B Medical Technologies, Inc.; Orangevale, CA.
References and additional information regarding the CoughAssist, including reimbursement information, usage protocol, and requests for an introduction and training CD, may be obtained by contacting the Respironics (800-345-6443). Or your physician can contact your regional DMERC Medical Director.
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