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License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

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This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

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  1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
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April 30, 2024

Practitioners! 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 that the patient has a condition that requires certain inhalation medication. Under the DME benefit, Medicare does not reimburse for inhalation drugs unless administered with a nebulizer compressor; however, coverage may be available through other Medicare benefits such as Part D (e.g., for metered dose inhalers).

The supplier must have a valid standard written order (SWO) before submitting a claim to the Medicare program.

A valid SWO must have the following elements:

  • Beneficiary's name or Medicare Beneficiary Identifier (MBI)
  • Order date
  • General description of the item
    • The description can be either a general description (e.g., wheelchair or hospital bed), a HCPCS code, a HCPCS code narrative, or a brand name/model number.
    • For equipment – In addition to the description of the base item, the SWO may include all concurrently ordered options, accessories or additional features that are separately billed or require an upgraded code (list each separately).
    • For supplies – In addition to the description of the base item, the DMEPOS order/prescription may include all concurrently ordered supplies that are separately billed (list each separately).
  • Quantity to be dispensed, if applicable
  • Treating practitioner name or NPI
  • Treating practitioner's signature

You do not need to list the quantity for the compressor, since only one compressor will be provided. However, you will need to list the quantity for inhalation medication the supplier may dispense at one time. You may also add identifying information such as the frequency or dosage (such as "twice per day" or "every six hours").

Your state may have more strict rules on orders than Medicare; this tends to be especially true for medication. It is important to follow the most stringent state rules and regulations when providing orders to the DME suppliers.

The DME MAC Nebulizers Local Coverage Determination (LCD) L33370External Website outlines the coverage criteria for the nebulizer, related compressor, and FDA–approved nebulizer drugs, and other related accessories/supplies.

The patient's diagnosis determines coverage. The charts below show the various types of nebulizers and inhalation drugs Medicare covers for specific disease categories and diagnoses. You can find the covered ICD-10 diagnosis codes listed by Group in the Nebulizers Policy Article (A52446)External Website.

Small Volume Nebulizers (A7003-A7005) & Related Compressor (E0570)

Covered Conditions and ICD-10-CM Codes that Support Medical Necessity Groups Inhalation Medications
Obstructive Pulmonary Disease (Group 8) Albuterol (J7611, J76713) Arformoterol (J7605) Budesonide (J7626) Cromolyn (J7631) Formoterol (J7606) Ipratropium (J7644) Levalbuterol (J7612, J7614) Metaproterenol (J7669) Revefenacin (J7677)
Cystic Fibrosis (Group 9) Dornase Alfa (J7639)
Cystic Fibrosis or Bronchiectasis (Group 10) Tobramycin (J7682)
HIV, Pneumocytosis, or Organ Transplants (Group 4) Pentamidine (J2545)
Persistent Pulmonary Secretions (Group 7) Acetylcysteine (J7608)

Large Volume Nebulizer (A7007, A7017) & Related Compressors (E0565, E0572), Combo Nebulizer with Compressor & Heater (E0585), Water/Saline (A4217 or A7018)

Covered Conditions and ICD-10-CM Codes that Support Medical Necessity Groups Inhalation Medication

Deliver humidity for persistent thick and tenacious pulmonary secretions to patients with:

  • Cystic fibrosis
  • Bronchiectasis
  • Tracheostomy
  • Tracheobronchial stent

(Group 5 codes)

Acetylcysteine (J7608)

Filtered Nebulizer (A7006) & Compressor (E0585 or E0572)

Covered Conditions and ICD-10-CM Codes that Support Medical Necessity Groups Inhalation Medication
  • HIV
  • Pneumocytosis
  • Complications of organ transplants

(Group 1 codes)

Pentamidine (J2545)

Small Volume Ultrasonic Nebulizer (E0574) and Accessories (A7013, A7014, A7016)

Covered Conditions and ICD-10-CM Codes that Support Medical Necessity Groups Inhalation Medication
Pulmonary hypertension with added coverage criteria
(Group 1 codes)
Iloprost (Q4074)
Tresprostinil (J7686)

The Nebulizers Local Coverage Determination (LCD) L33370External Website lists 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.

If a drug used with a nebulizer is considered not reasonable and necessary, the compressor, the nebulizer, and other related accessories/supplies will also be denied as not reasonable and necessary.

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