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:
|
A five element order (5EO) with the following:
|
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 |
---|---|
|
|
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) |
|
|
|
|
|
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