Skip to Main Content

Print | Bookmark | Email | Font Size: + |

December 15, 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
  • 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 NebuliObstzer 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)
  • Arformoterol (J7605)
  • Budesonide (J7626)
  • Cromolyn (J7631)
  • Formoterol (J7606)
  • Ipratropium (J7644)
  • Levalbuterol (J7612, J7614)
  • Metaproterenol (J7669)
  • Dornase Alpha J7639
  • Tobramycin J7682
  • Pentamidine J2545
  • Acetylcysteine J7608


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

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved