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November 28, 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.