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Article Detail - JD DME

RETIRED - Treprostinil Inhalation Solution (Tyvaso) - Coding and Coverage

IMPORTANT: THIS DOCUMENT CONTAINS OUTDATED INFORMATION.Content Provided on this page contains outdated information and instruction and should not be considered current. Noridian is providing this archived information for research purposes only. This archived article contains previously issued instructions that have since been updated or are no longer applicable for Medicare billing purposes.

Article retired due to content incorporation into the applicable Local Coverage Determination or related Policy Article.

Original Effective Date: 07/31/2010           
Revision Effective Date: 11/01/2013

Effective for dates of service on or after July 31, 2009 treprostinil inhalation solution and the nebulizer and related accessories used to administer it are covered for the treatment of patients with primary pulmonary hypertension (ICD-9 diagnosis codes 416.0 and 416.8) and who meet the criteria for iloprost as described in the Nebulizers LCD.

Treprostinil inhalation solution is coded J7699KO. One unit of service equals one ampule. The claim should identify the name of the drug and the number of ampules dispensed. The submitted charge for J7699KO should just reflect the drug itself - not the nebulizer or accessories.

The Optineb® ir (Nebu-tec) nebulizer used to administer treprostinil inhalation should be billed with code E0574 (ultrasonic nebulizer). Because E0574 is in the capped rental category, in order for it to be paid by Medicare, it must be billed as a rental (RR modifier). If the Optineb® ir nebulizer is billed as a purchase (NU modifier), it will be denied and the drugs and accessories will also be denied. The submitted charge for code E0574 should just reflect the charges for the nebulizer - not the drug or accessories.

If two Optineb® ir nebulizers are provided and the submitted charges reflects two nebulizers, you must bill 2 units of service on the claim line for E0574RR. Medicare will only pay for one nebulizer.

Accessories used in conjunction with the Optineb® ir nebulizer should be billed on separate claim lines. The dome and mouthpiece should be billed with code A7016. Other accessories should be billed with code A9999. When code A9999 is used, the claim must clearly describe the type and quantity of accessories provided.

This information will be added to the next revision of the Nebulizers policy. For additional coverage, coding, and documentation requirements, suppliers should refer to the Nebulizer LCD and related Policy Article on the DME MAC web sites.


            Last Updated Thu, 10 Jan 2019 12:40:37 +0000