Nebulizers can be covered if the member’s ability to breathe is severely impaired. Lung diseases such as chronic obstructive pulmonary disease (COPD) and asthma are characterized by airflow limitation that may be partially or completely reversible. Pharmacologic treatment with bronchodilators is used to prevent and/or control daily symptoms that may cause disability for persons with these diseases.
These medications are intended to improve the movement of air into and from the lungs by relaxing and dilating the bronchial passageways. Beta-adrenergic agonists are a commonly prescribed class of bronchodilator drugs. They can be administered via nebulizer, metered-dose inhaler, orally, or dry powdered inhaler.
CMS Need Nebulizer 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. 5-element order (5EO) WOPD (written order prior to delivery) is required and must include the following elements:
- Beneficiary’s name
- Item of DME ordered. this may be general (for example, hospital bed) or more specific (for example, continuous glucose monitor [CGM])
- Signature of the prescribing practitioner
- Prescribing practitioner’s National Provider Identifier (NPI)
- The date of the order
- A completed 5EO within 6 months after the required Affordable Care Act (ACA) 6407 face-to-face examination
- The supplier’s receipt of the 5EO before delivery of the listed item(s)
- A date stamp or equivalent must be used to document the 5EO receipt date
Billing Scenarios and Correct CPT Codes
- Time is a factor when billing the service. If the treatment is less than 1 hour, you would bill Current Procedural Terminology (CPT) code 94640, ‘Pressurized or non-pressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device.’CMS policy states that an episode of care begins when a patient arrives at a facility for treatment and terminates when the patient leaves the facility. CPT code 94640 should be reported only once during an episode of care, regardless of the number of separate inhalation treatments that are administered. This means that if the patient requires two separate nebulizer treatments during the same visit, you would still only bill CPT code 94640 once.
- However, if a patient receives ‘back-to-back’ nebulizer treatments exceeding 1 hour, (which rarely occurs in urgent care), bill CPT code 94644, ‘Continuous inhalation treatment with aerosol medication for acute airway obstruction; the first hour,’ and CPT code 94645, ‘Continuous inhalation treatment with aerosol medication for acute airway obstruction; each additional hour,’ as appropriate, instead of CPT code 94640.
- If the patient receives a nebulizer treatment of less than 1 hour (CPT code 94640) during an episode of care and subsequently returns on the same date of service to the urgent care to receive another nebulizer treatment of less than 1e hour, then you would bill CPT code 94640 and append modifier -76, ‘Repeat procedure or service by the same physician or other qualified health care professional’ for the second treatment, since the return visit would be considered a separate episode of care. CPT code 94640 cannot be billed on the same date of service as CPT codes 94644 and 94655.
- The medications administered in the urgent care setting are most commonly a form of albuterol. You will find the correct codes to use in the ‘Healthcare Common Procedure Coding System Level II’ (HCPCS) coding manual. Below is a list of Federal Drug Administration (FDA)-approved medication containing albuterol:
- 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’
- J7620, ‘Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, FDA-approved final product, non-compounded, administered through DME’
- There are several respiratory or pulmonary conditions that may qualify for inhalation treatment coding, such as Asthma; Acute bronchitis; Chronic obstructive pulmonary disease (COPD); Pneumonia; Acute bronchospasm; Cough; Wheezing; and Shortness of breath.
Documentations
Appropriate documentation for Nebulizers must include the following items:
- A recent order by the treating physician for refills,
- A recent change in prescription, and
- Beneficiary’s medical record within 12 months of the date of service showing usage of the item
When a shipping service makes a delivery, the following documentation elements must be present:
- Beneficiary’s name
- Delivery address
- Delivery service’s package identification number, supplier invoice number, or alternative method that links the supplier’s delivery documents with the delivery service’s records
- A description of the items being delivered. The description can be either a narrative description (for example, a lightweight wheelchair base), and HCPCS Level II code, the long description of an HCPCS Level II code, or a brand name/model number
- Quantity delivered
- Date delivered
- Evidence of delivery
When you are ordering nebulizers and the drugs used in them for your patients, documentation plays a crucial role. Choosing the right CPT also ensures timely reimbursement without denials. Medical billing for Nebulizers is a time-consuming activity that requires constant follow-ups in case of denials.
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FAQs:
1. What conditions qualify for nebulizer coverage?
Nebulizers are covered for severe breathing impairments due to conditions like COPD and asthma, which cause airflow limitations.
2. What is required for a nebulizer prescription according to CMS?
A face-to-face evaluation by a physician is needed to document the necessity of the nebulizer, along with a 5-element order before delivery.
3. Which CPT codes are used for nebulizer treatments?
CPT code 94640 is used for treatments under 1 hour, while CPT codes 94644 and 94645 are for continuous treatments exceeding 1 hour.
4. What documentation is needed for nebulizer billing?
Documentation must include a recent physician order, patient medical records, and delivery details such as the beneficiary’s name and the date delivered.
5. How should modifiers be used in nebulizer billing?
Modifier -76 is used when billing for a repeat nebulizer treatment on the same date, while CPT code 94640 cannot be billed with CPT codes 94644 or 94645 on the same date.
