Nebulizers - JA DME
Nebulizers
Coverage
- Durable Medical Equipment Reference List National Coverage Determination (NCD)
- Nebulized Beta Adrenergic Agonist Therapy for Lung Diseases NCD
- Nebulizers Local Coverage Determination (LCD)
- Nebulizers Policy Article
Documentation
- Standard Documentation Requirements for All Claims Submitted to DME MACs
- Clinician Checklist Nebulizers [PDF] - Checklist to assist clinicians with coverage and documentation requirements
- Clinician Letter - Documentation of Continued Medical Necessity [PDF] - Letter may be sent to clinicians to help obtain documentation
- Clinician Letter - Durable Medical Equipment - An Easy Option for Documenting Continued Use [PDF] - Letter may be sent to clinicians to help obtain documentation
- Clinician Letter - Medical Records [PDF] - Letter may be sent to clinicians to help obtain documentation
- Clinician Letter - Nebulizer [PDF] - Letter may be sent to clinicians to help obtain documentation
- Nebulizers and Respiratory Drugs Documentation Checklist [PDF] - Checklist to ensure suppliers gather all required documentation
Reviews/Audits
- Medical Review - View notifications/findings of pre/post claim reviews completed by Noridian Medical Review
Tips
Maximum Frequency replacement accessories
- A4619, A7006, A7525, A7015: One/Month
- A7003, A7007, A7012, A7013: Two/ Month
- A7004: Two/ Month (in addition to A7003)
- A7005: One/3 months only with K0730
- A7005: One/6 months
- A7010: One Unity (100ft.)/ 2 month
- A7014: One/3 months
- A7017, E1372: One/3 years
- A7016: Two/Year
340B Drug Pricing Program Modifier
- JG - drug or biological acquired with 340B drug pricing program
- Effective for claims with dates of service on or prior to January 1, 2024
- Discontinued effective December 31, 2024
- TB - drug or biological acquired with 340B drug pricing program
- Effective for claims with dates of service on or prior to January 1, 2024
- Required for claims with dates of service on or after January 1, 2025
Drug Waste Modifiers
- JW - drug amount discarded/not administered to any patient
- Indicated for discarded drugs and biologicals from "single use vials or single use packages."
- Effective for claims with dates of service on or after January 1, 2017, if the coverage criteria for the infusion drugs are not met, claims billed for drug wastage with the JW modifier will be denied as not reasonable and necessary.
- Effective for claims with dates of service on or after January 1, 2017, claims lines billed for drug wastage without a JW modifier will be denied as not reasonable and necessary.
- JZ - zero drug amount discarded/not administered to any patient
- Effective for use January 1, 2023, and,
- Required for use on applicable claims with dates of service July 1, 2023
- Indicated when there are no discarded amounts from "single use vials or single use packages."
Drugs: Maximum Milligrams/Month
- Acetylcysteine: 74 grams/month
- Albuterol: 465 mg/ month
- Albuterol/Lpratropium combination: 186 units/ month
- Arformoterol: 930 micrograms/month-62 units/month
- Budesonide: 62 units/month
- Cromolyn Sodium: 2480 mg/month 0248 units/month
- Dornase Alfa: 78 mg/month
- Formoterol: 1240 micrograms/month- 62 units/month
- Ipratropium Bromide: 93 mg/month
- Levalbuterol: 232.5 mg/month-465 units/month (see below for exception)
- Metaproterenol: 2800mg/month-280 units/month
- Pentamidine: 300mg/months
- Revefenacin: 5250 mcg/month
- Treprostinil: 31 units/month
- Sterile Saline or water, 10ml/unit (A4216, A4218): 56 units/month
- Distilled Water, sterile water, sterile saline in large volume nebulizer: 18 liters/month
Resources
Last Updated Sep 04 , 2024
