Wednesday, November 15, 2017

Nebulizer cpt code list - A7017, A7018, A7007

For a DME item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act §1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.

Nebulizers require an in-person or face-to-face interaction between the beneficiary and their treating physician prior to prescribing the item, specifically to document that the beneficiary was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered. A dispensing order is not sufficient to provide these items. A WOPD (written order prior to delivery) is required.

Detailed documentation requirements are outlined in Nebulizer LCD

HCPCS Code Description

A4217 Sterile water/saline, 500 ml
A4218 Sterile saline or water, metered dose dispenser, 10 ml
A4619 Face tent
A7003 Administration set, with small volume nonfiltered pneumatic nebulizer, disposable
A7004 Small volume nonfiltered pneumatic nebulizer, disposable
A7005 Administration set, with small volume nonfiltered pneumatic nebulizer, nondisposable
A7006 Administration set, with small volume filtered pneumatic nebulizer
A7007 Large volume nebulizer, disposable, unfilled, used with aerosol compressor
A7008 Large volume nebulizer, disposable, prefilled, used with aerosol compressor (noncovered per LCD) A7009 Reservoir bottle, non-disposable, used w/ large volume ultrasonic nebulizer (noncovered per LCD)
A7010 Corrugated tubing, disposable, used with large volume nebulizer, 100 feet
A7011 Corrugated tubing, non-disposable, used with large volume nebulizer, 10 feet
A7012 Water collection device, used with large volume nebulizer
A7013 Filter, disposable, used with aerosol compressor or ultrasonic generator
A7014 Filter, nondisposable, used with aerosol compressor or ultrasonic generator
A7015 Aerosol mask, used with DME nebulizer
A7016 Dome and mouthpiece, used with small volume ultrasonic nebulizer
A7017 Nebulizer, durable, glass or autoclavable plastic, bottle type, not used with oxygen
A7018 Water, distilled, used with large volume nebulizer, 1000 ml
A7525 Tracheostomy mask, each
G0333 Pharmacy dispensing fee for inhalation drug(s); initial 30-day supply as a beneficiary
J2545 Pentamidine isethionate, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose form, per 300 mg
J7604* Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram
J7605 Arformoterol, inhalation solution, FDA approved final product, non-compounded, administered through DME, unit dose form, 15 micrograms
J7606 Formoterol fumarate, inhalation solution, FDA approved final product, noncompounded, administered through DME, unit dose form, 20 micrograms
J7607* Levalbuterol, inhalation solution, compounded product, administered through DME, concentrated form, 0.5 mg
J7608 Acetylcysteine, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose form, per gram
J7609* Albuterol, inhalation solution, compounded product, administered through DME, unit dose, 1 mg
J7610* Albuterol, inhalation solution, compounded product, administered through DME, concentrated form, 1 mg
J7611 Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, 1 mg
J7612 Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, 0.5 mg
J7613 Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 1 mg
J7614 Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 0.5 mg
J7615* Levalbuterol, inhalation solution, compounded product, administered through DME, unit dose, 0.5 mg


QUESTIONS AND ANSWERS

Q: Is a large volume ultrasonic nebulizer (HCPCS E0575) covered by Medicare?

A: A large volume ultrasonic nebulizer offers no proven clinical advantage over a pneumatic compressor and nebulizer and will be denied as not reasonable and necessary.


Q: Are compound inhalation solutions covered by Medicare?

A: CMS revoked coverage of compounded inhalation solutions in 2007.


Q: Are there any restrictions around nebulizers and home oxygen use?

A large volume pneumatic nebulizer (HCPCS E0580) and water or saline (HCPCS A4217 or A7018) are not separately payable and should not be separately billed when used for beneficiaries with rented home oxygen equipment.


Medical Records

If the claim includes a nebulizer with compressor (E0570), the medical records include a face-to-face examination by the treating physician that meets the following requirements: The examination occurred within 6 months prior to the date of the written order that was obtained prior to delivery; and

The examination documents that the beneficiary was evaluated and/or treated for a condition that supports the need for a nebulizer with compressor in order to administer inhalation drugs.

A date stamp or similar indicator verifies that the supplier received a copy of the F2F note on or before the date of delivery.

Continued Medical Need for the Equipment/Accessories/Supplies is Verified by Either:

A refill order from the treating physician dated within 12 months of the date of service under review; or

A change in prescription dated within 12 months of the date of service under review; or

A medical record, dated within 12 months of the date of service under review, that shows usage of the item. Claims for a Small Volume Ultrasonic Nebulizer (E0574)

A small volume ultrasonic nebulizer is reasonable and necessary to administer treprostinil inhalation solution only (See Treprostinil/Iloprost Inhalation Solution Checklist). Claims for code E0574 used with other inhalation solutions will be denied as not reasonable and necessary. Claims for HCPCS Code E1399 (Miscellaneous Equipment or Accessories)

The claim includes a clear description of the item including:

The manufacturer’s name,

The model name/number,Pricing information, and An explanation of medical necessity. Claims for HCPCS Code J7699 (NOC Nebulizer Drug Code)

The claim is accompanied by:

Detailed order information as described in the written order requirements,

A clear statement of the number of ampules/bottles of solution dispensed, and Documentation of the medical necessity of the drug for that beneficiary.

It is expected that the beneficiary’s medical records will reflect the need for the care provided. These records are not routinely submitted to the DME MAC but must be available upon request. Therefore, while it is not a requirement, it is a recommendation that suppliers obtain and review the appropriate medical records and maintain a copy in the beneficiary’s file.

Additionally, while the nebulizer drug LCD does not require suppliers who only provide the nebulizer to keep a file copy of the written order for the drug(s), it is strongly recommended that the supplier do so. In the event of a claim audit by the DME MAC, CERT, or ZPIC contractor, documentation the supplier will be required to submit in order to verify the medical necessity for the nebulizer will include a copy of the detailed written order for the drug(s). Failure to provide the written order in a timely manner could result in denial of the nebulizer claim and an overpayment assessment.

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