>Physicians! Are You Ordering Nebulizers and Inhalation Medication For Your Patient?
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December 12, 2016

Physicians! 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 physician 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 Item(s) to be dispensed
Prescribing practitioner’s name Frequency of use
Date of the order Quantity to be dispensed
Detailed description of the item(s) Number of refills
Prescribing practitioner’s signature and signature date  

 

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 5 Codes)
Acetylcysteine J7608
Diagnosis codes that support medical necessity Group 5 codes section for applicable diagnoses.

 

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/db04b968-5cd0-4445-9707-0fe51d34ec80
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/db04b968-5cd0-4445-9707-0fe51d34ec80


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