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 the patient has a condition that requires certain inhalation medication (as outlined below).

For the nebulizer compressor only (E0570, E0575, E0580, E0585, K0730), the following is required prior to delivery:

Nebulizer - Documentation prior to delivery Nebulizer - Prescription prior to delivery
A face-to face-visit within six months prior to prescribing:
  • Documenting the patient was evaluated and/or treated for the condition supporting need for the item(s) ordered
A five element order (5EO) with the following:
  • Patient name
  • Item ordered
  • National Provider Identifier (NPI) of prescribing practitioner
  • Date of the order
  • Prescribing practitioner signature

 

For any item provided based on clinician contact with a DME supplier to provide the service (i.e., dispensing order), the supplier must obtain a detailed written order (DWO) before submitting a claim. The detailed written order must contain:

Detailed Written Order (DWO) elements prior to billing Items provided on a periodic basis, inhalation drugs and related accessories/supplies must include
  • Beneficiary's Name
  • Beneficiary's name
    Prescribing practitioner's name
  • Date of the order
  • Detailed description of the item(s)
  • Prescribing practitioner's signature and signature date
  • Item(s) to be dispensed
  • Frequency of use
  • Quantity to be dispensed
  • Number of refills

 

The DME MAC Nebulizers Local Coverage Determination (LCD) L33370 outlines the coverage criteria for the nebulizer, related compressor, and FDA –approved nebulizer drugs and other related accessories/ supplies.

The charts below provide the various types of nebulizers and inhalation drugs covered by Medicare for specific disease categories.

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

Persistent thick and tenacious Pulmonary Secretions

  • Cystic Fibrosis
  • Bronchiectasis
  • Tracheostomy
  • Tracheobronchial Stent

(Group 5 Codes)

Acetylcysteine J7608

Diagnosis codes that support medical necessity Group 5 codes section for applicable diagnoses.

 

Compressor E0565 or E0572
Filtered Nebulizer A7006

Persistent thick and tenacious Pulmonary Secretions

  • HIV
  • Pneumocystosis
  • Complications of Organ Transplants

(Group 1 Codes)

Pentamidine J2545

 

Small Volume Ultrasonic Nebulizer E0574

Accessories A7013, A7014, A7016

Pulmonary Hypertension with Additional Criteria

(Group 1 Codes)

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 none of the drugs (as outlined above) used with a nebulizer are covered; the compressor, the nebulizer, and other related accessories/supplies will be denied as not reasonable and necessary.

Local Coverage Determinations for Nebulizers

Jurisdiction A: https://med.noridianmedicare.com/documents/2230703/7218263/Nebulizers

Jurisdiction B: http://www.cgsmedicare.com/jb/coverage/lcdinfo.html

Jurisdiction C: http://www.cgsmedicare.com/jc/coverage/lcdinfo.html

Jurisdiction D: https://med.noridianmedicare.com/documents/2230703/7218263/Nebulizers

 

Last Updated Oct 08, 2018