Clinicians! Are You Ordering Nebulizers and Inhalation Medication for Your Patient - JA DME
Clinicians! Are You Ordering Nebulizers and Inhalation Medication for Your Patient?
Medicare will consider coverage of a nebulizer, compressor and related accessories when the patient’s medical record verifies that the patient has a condition that requires certain inhalation medication. Under the DME benefit, Medicare does not reimburse for inhalation drugs unless they are administered with a nebulizer compressor; however, coverage may be available through other Medicare benefits such as Part D (e.g., for metered dose inhalers).
For any item provided based on physician contact with a DME supplier to provide the service, the supplier must have a valid standard written order (SWO) before submitting a claim to the Medicare program.
An order must contain the following elements to be considered a valid SWO:
- Beneficiary’s name or Medicare Beneficiary Identifier (MBI)
- Order date
- General description of the item
- The description can be either a general description (e.g., wheelchair or hospital bed), a HCPCS code, a HCPCS code narrative, or a brand name/model number
- For equipment - In addition to the description of the base item, the SWO may include all concurrently ordered options, accessories or additional features that are separately billed or require an upgraded code (List each separately).
- For supplies - In addition to the description of the base item, the DMEPOS order/ prescription may include all concurrently ordered supplies that are separately billed (List each separately)
- Quantity to be dispensed, if applicable
- Treating practitioner name or NPI
- Treating practitioner’s signature
One clarifying note about the "quantity" element listed above. It’s not necessary for the compressor to have a quantity listed, since only one compressor will be provided. It will be necessary, however, for a quantity to be listed for inhalation medication since a certain number of doses/vials are likely to be provided at one time. The standard written order may also include identifying information such as the frequency or dosage (such as "twice per day" or "every six hours") to provide information about the usage of the drug.
The preceding information are the requirements for Medicare only. Your state may have more strict rules on orders than Medicare - this tends to be especially true for medication. As such, it is important to follow the most stringent state rules and regulations when providing orders to the DME suppliers.
The DME MAC Nebulizers Local Coverage Determination (LCD) L33370 (https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33370&ContrID=140) outlines the coverage criteria for the nebulizer, related compressor, and FDA -approved nebulizer drugs and other related accessories/supplies.
This is a diagnosis-specific policy for the determination of coverage. The charts below provide the various types of nebulizers and inhalation drugs covered by Medicare for specific disease categories and diagnosis. Drug-specific diagnoses indicated by Group codes are found in the Nebulizer Policy Article (A52446) (https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52466&ContrID=140).
Small Volume Nebulizer A7003-A7005 Compressor E0570
| Obstructive Pulmonary Disease | Cystic Fibrosis | Cystic Fibrosis or Bronchiectasis | HIV, Pneumocystosis, or Organ Transplants | Persistent Pulmonary Secretions |
|---|---|---|---|---|
| Group 8 Codes | Group 9 Codes | Group 10 Codes | Group 4 Codes | Group 7 Codes |
| Albuterol (J7611, J7613) | Dornase Alpha (J7639) | Tobramycin (J7682) | Pentamidine (J2545) | Acetylcysteine (J7608) |
| Arformoterol (J7605) | ||||
| Budesonide (J7626) | ||||
| Cromolyn (J7631) | ||||
| Formoterol (J7606) | ||||
| Ipratropium (J7644) | ||||
| Levalbuterol (J7612, J7614) | ||||
| Metaproterenol (J7669) |
Large Volume Nebulizer A7007, A7017
Compressor E0565, E0572
Water/Saline A4217 or A7018 or Combination Code E0585
Deliver Humidity for Persistent thick and tenacious Pulmonary Secretions
- Cystic Fibrosis
- Bronchiectasis
- Tracheostomy
- Tracheobronchial Stent
(Group 5 Codes)
Acetylcysteine (J7608)
Filtered Nebulizer A7006
Compressor E0565 or E0572
- HIV
- Pneumocystosis
- Complications of Organ Transplants
(Group 1 Codes)
Pentamidine (J2545)
Small Volume Ultrasonic Nebulizer E0574
Accessories A7013, A7014, A7016
Pulmonary Hypertension with Additional Coverage Criteria
(Group 1 Codes)
Iloprost (Q4074)
Tresprostinil (J7686)
The Nebulizers Local Coverage Determination (LCD) L33370 provides the usual maximum frequency of replacement of related accessories/supplies as well as the maximum milligrams per month of inhalation drugs that are reasonable and necessary.
Please note: If a drug used with a nebulizer is considered not reasonable and necessary, the compressor, the nebulizer, and other related accessories/supplies will also be denied as not reasonable and necessary.
Local Coverage Determinations for Nebulizers
- Jurisdiction A: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33370
- Jurisdiction B: http://www.cgsmedicare.com/jb/coverage/lcdinfo.html
- Jurisdiction C: http://www.cgsmedicare.com/jc/coverage/lcdinfo.html
- Jurisdiction D: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33370
