A Collaboration Webinar presented by the Nebulizers A/B ...€¦ · Once you are connected to the webinar, ... (CGM) are not enforced • External Infusion Pumps (L33794); • Infusion

Revised: May 2020Revised: May 2020

Nebulizers & Inhalation Medication

A Collaboration Webinar presented by the

A/B MACs & the DME MACsMay 2020

© 2020 Copyright, CGS Administrators, LLC.


Once you are connected to the webinar, select “Handouts”

Select “Nebulizers March 2020.pdf” to download the presentation

TODAY’S PRESENTATION

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Revised: May 2020

Participants CGS Administrators, LLC: http://www.cgsmedicare.com

First Coast Service Options, Inc.: http://www.fcso.com/

National Government Services: http://ngsmedicare.com/

Noridian: http://www.noridianmedicare.com/

Novitas Solutions: https://www.novitas-solutions.com/

Palmetto GBA: http://www.palmettogba.com/

WPS Government Health Administrators: https://www.wpsgha.com/

© 2020 Copyright, CGS Administrators, LLC.4

http://www.cgsmedicare.com/

http://www.fcso.com/

http://ngsmedicare.com/

http://www.noridianmedicare.com/

https://www.novitas-solutions.com/

http://www.palmettogba.com/

https://www.wpsgha.com/

Revised: May 2020

Agenda 2019 CERT Data

Coverage Criteria

Documentation Requirements

Resources



2019 CERT Data


Revised: May 2020

CERT Errors – 2019 CERT ReportThe 2019 CERT Improper Payment Data Report was published on December 12, 2019. This report can be found on https://www.cms.govand downloaded at: https://www.cms.gov/files/document/2019-medicare-fee-service-supplemental-improper-payment-data.pdf

The overall DMEPOS CERT Error Rate was 30.7%.

Nebulizers and related inhalation medication had a 12.3% error rate with 80% of the errors from insufficient documentation.


https://www.cms.gov/

https://www.cms.gov/files/document/2019-medicare-fee-service-supplemental-improper-payment-data.pdf


Coverage Criteria


Revised: May 2020

Coverage Criteria OverviewThe following slides represent the foundational coverage criteria for inhalation medication and their related nebulizers/compressors.

If the inhalation medication used with the nebulizer is not covered, the nebulizer, compressor, and related accessories will be denied as not reasonable and necessary.

This policy is a “diagnosis-driven” LCD. There are specific ICD-10 codes associated with each inhalation medication. The medical condition must be outlined in the medical record and the ICD-10 code must be billed on the Medicare claim to the DME MAC.


Revised: May 2020

Coverage Criteria


SMALL VOLUME NEBULIZER A7003-A7005COMPRESSOR 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)

AlbuterolArformoterolBudesonideCromolyn

FormoterolIpratropiumLevalbuterol

Metaproterenol

Dornase AlphaJ7639

TobramycinJ7682

PentamidineJ2545

AcetylcysteineJ7608

Reference the “Diagnosis Codes that Support Medical Necessity” section of the Policy Article for applicable diagnoses.

Revised: May 2020

Coverage Criteria


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 | BRONCHIECTASISTRACHEOSTOMY | TRACHEOBRONCHIAL STENT

Acetylcysteine J7608

Revised: May 2020

Coverage Criteria


FILTERED NEBULIZER A7006 COMPRESSOR E0565 or E0572

HIV | PNEUMOCYSTOSIS | COMPLICATIONS OF ORGAN TRANSPLANTS

Group 1 Codes

Pentamidine J2545

Revised: May 2020

Coverage Criteria


SMALL VOLUME ULTRASONIC NEBULIZER E0574 Accessories A7013, A7014, A7016

Pulmonary Hypertension with Additional CriteriaGroup 1 Codes

Tresprostinil J7686

Revised: May 2020

Coverage Criteria


CONTROLLED-DOSE INHALATION DELIVERY SYSTEM K0730

Pulmonary Hypertension with Additional Criteria

Group 11 Codes

Iloprost Q4074

Revised: May 2020

Coverage Criteria


Pulmonary Artery Hypertension

TREPROSTINIL J7686 ILOPROST Q4074}This: Or this: But NOT this:PRIMARY Secondary to: Secondary to:PULMONARY HYPERTENSION

• connective tissue disease• thromboembolic disease• HIV infection• cirrhosis• diet drugs• congenital left-to-right shunts

• Pulmonary venous hypertension• Disorders of the respiratory system

Revised: May 2020

Coverage Criteria

If acceptable diagnosis is met, then the following must be met:

• Progression despite maximal medical and/or surgical treatment

• Mean pulmonary artery pressure is > 25 mm Hg at rest or > 30 mm Hg with exertion

• Significant symptoms present (i.e., severe dyspnea on exertion, and either fatigability, angina, or syncope)

• Treatment with oral calcium channel blocking agents tried and failed, or has been considered and ruled out


continued….

TREPROSTINIL J7686 ILOPROST Q4074}

Revised: May 2020

Coverage CriteriaA controlled dose inhalation drug delivery system (K0730) is covered:

It is reasonable and necessary to deliver iloprost (Q4074) to beneficiaries with pulmonary hypertension only. (Group 11 Codes)

Claims for code K0730 for use with other inhalation solutions will be denied as not reasonable and necessary.

If all of the criteria listed in the LCD are not met, code E0574 and the related drug (J7686) or code K0730 and the related drug Q4074 will be denied as not reasonable and necessary.


Revised: May 2020

Coverage Criteria


LARGE VOLUME ULTRASONIC NEBULIZER E0575

Please note – there is no proven clinical advantage over a pneumatic compressor and nebulizer and will be denied as not reasonable and necessary.

Revised: May 2020

Related accessories are separately payable if the compressor is covered and the accessories are medically necessary.

The following table lists the compressor/generator, which is related to the accessories described:

Coverage Criteria-Accessories

Compressor/Generator Related Accessories

E0565 A4619, A7006, A7007, A7010, A7012, A7013, A7014, A7015, A7017, A7525, E1372

E0570 A7003, A7004, A7005, A7006, A7013, A7015, A7525

E0572 A7006, A7014

E0574 A7014, A7016

E0585 A4619, A7006, A7010, A7012, A7013, A7014, A7015, A7525

K0730 A7005


Revised: May 2020

Accessories: Usual MaximumA4619 (1/month) A7003 (2/month) A7004 (2/month)

in addition to the A7003

A7005 (1/6 months) A7005 (1/3 months) only with K0730 A7006 (1/month)

A7007 (2/month) A7010 (1 unit (100 ft.)/2 months)

A7012 (2/month) A7013 (2/month) A7014 (1/3 months)

A7015 (1/month) A7016 (2/year) A7017 (1/3 yrs)

A7525 (1/month) E1372 (1/3 yrs)


Revised: May 2020

Inhalation Drugs and SolutionsAcetylcysteine(up to 74g/mo)

Albuterol (up to 465 mg/mo)

Albuterol/Ipratroprium combination(up to 186 units/mo)

Arformoterol(up to 930 mcg/mo - 62 units/mo)

Budesonide(up to 62 unit/mo)

Cromolyn sodium(up to 2480 mg/mo 248 units/mo)

Dornase alpha(up to 78 mg/mo)

Formoterol (up to 1240 mcg/mo - 62 units/mo)

Ipratroprium Bromide (up to 93mg/mo)

Levalbuterol(up to 232.5 mg/mo – 465 units/mo)

Metaproterenol(up to 2800 mg/mo - 280 units/mo)

Pentamidine(up to 300 mg/mo)

Treprostinil

(up to 31 units/mo)

Sterile saline or water (up to 56 units/mo) A4216, A4218

Distilled water, sterile water, or sterile saline in large volume nebulizer (up to 18 liters/mo)


Revised: May 2020

When albuterol, levalbuterol, or metaproterenol are prescribed as rescue/supplemental medication for beneficiaries who are taking formoterol or arformoterol, the maximum milligrams/month are:

Inhalation Drugs and Solutions

Inhalation Drugs and Solutions Maximum Milligrams/Month

Albuterol 78 mg/month

Albuterol/Ipratroprium combination 31 units/month

Levalbuterol 39 mg/month – 78 units/month

Metaproterenol 470 mg/month – 47 units/month


Revised: May 2020

Non-Coverage


Large volume pneumatic nebulizer (E0580) and water or saline used with oxygen equipment

Prefilled disposable large volume nebulizer (A7008)

Albuterol, levalbuterol and metaproterenol used at same time

Formoterol and arformoterol used at the same time

Albuterol sulfate (J7611, J7613), levalbuterol and/or ipratropiumbromide (J7644) billed with J7620


Documentation Requirements


Revised: May 2020

Medical Record Documentation


MEDICAL RECORD:

• Physician’s office notes

• Hospital notes/records

• Nursing facilities records

• Home health records

• Other health care professionals without financial motive

=

SUPPLIER-PRODUCED RECORDS

REASONABLE& NECESSARY

Revised: May 2020

Medical Record Documentation Supplier-produced records, even if signed by the ordering physician, and

attestation letters (e.g. letters of medical necessity) are deemed not to be part of a medical record for Medicare payment purposes.

Templates and forms, including CMS Certificates of Medical Necessity, are subject to corroboration with information found in the Medicare beneficiary’s medical record.

Information contained directly in the contemporaneous medical record is the source required to justify payment except as noted elsewhere for prescriptions and CMNs.


Revised: May 2020

Standard Written OrderFor dates of service on and after January 1, 2020, an SWO must be communicated to the supplier prior to claim submission and must contain all of the following:

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

© 2020 Copyright CGS Administrators, LLC.27

27

Revised: May 2020

New Order Requirements When there is a change in:

• Supplier

• Item(s) provided

• Frequency of use/dosage

• Amount prescribed

• The length of need, or when a previously established length of need expires

State law requirement


Revised: May 2020

Continued Medical Need Continued medical need can occur with the following:

• Timely medical record where the medical condition is discussed/reviewed/evaluated

– “Timely” is considered within 12 months of the date of service in question.

• Recent order or prescription



COVID-19 DME MACs


Revised: May 2020

Clinical Indications for CoverageEffective for claims with dates of service on or after March 1, 2020 and for the duration of this COVID-19 PHE

Clinical indications for coverage found in respiratory, home anticoagulation management, infusion pump, and therapeutic continuous glucose monitor NCDs or LCDs will not be enforced

• Home Oxygen (NCD 240.2)

• Infusion Pumps (NCD 280.14)

• Continuous Positive Airway Pressure for Obstructive Sleep Apnea (NCD 240.4)

• Intrapulmonary Percussive Ventilator (NCD 240.5)

• Oxygen and Oxygen Equipment (L33797);

• Positive Airway Pressure Devices for the Treatment of Obstructive Sleep Apnea (L33718);

• Oral Appliances for the Treatment of Obstructive Sleep Apnea (L33611)


• Respiratory Assist Devices (L33800);

• Mechanical In-exsufflation Devices (L33795)

• High Frequency Chest Wall Oscillation (L33785)

• Nebulizers (L33370)

• Glucose Monitors (L33822) – Only clinical indications for Therapeutic Continuous Glucose Monitors (CGM) are not enforced

• External Infusion Pumps (L33794);

• Infusion Pumps (NCD 280.14)

Revised: May 2020

Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency

Treating practitioners and suppliers must still:

• Provide a standard written order (SWO) for all items.

– All items (with the exception of PMDs) can be:

» Can be provided via a verbal order

» A signature is required prior to submitting claims for payment but the order can be signed electronically.

• Ensure the items or services are reasonable and necessary.

• Document the medical necessity for all services.

– Documentation must be available upon reques.t

The DME MACs will resume enforcement of clinical indications for coverage at the conclusion of the PHE.



DME MAC Jurisdictional

Resources


Revised: May 2020

Noridian Healthcare SolutionsJurisdiction A Resources

Website: https://med.noridianmedicare.com/web/jadme

IVR, Supplier Contact Center, and Telephone Reopenings: 1.866.419.9458

Noridian Medicare Portal: https://med.noridianmedicare.com/web/jadme/topics/nmp

LCDs and Policy Articles: https://med.noridianmedicare.com/web/jadme/policies/lcd/active

34 © 2020 Copyright, CGS Administrators, LLC.

https://med.noridianmedicare.com/web/jadme

https://med.noridianmedicare.com/web/jadme/topics/nmp

https://med.noridianmedicare.com/web/jadme/policies/lcd/active

Revised: May 2020

CGS Administrators, LLCJurisdiction B Resources

Website: http://www.cgsmedicare.com/jb

IVR Unit: 1.877.299.7900

myCGS Web Portal: http://www.cgsmedicare.com/jb/mycgs/index.html

Customer Service: 1.866.590.6727

Telephone Re-openings: 1.844.240.7490

LCDs and Policy Articles: http://www.cgsmedicare.com/jb/coverage/lcdinfo.html


http://www.cgsmedicare.com/jb

http://www.cgsmedicare.com/jb/mycgs/index.html

http://www.cgsmedicare.com/jb/coverage/lcdinfo.html

Revised: May 2020

CGS Administrators, LLCJurisdiction C Resources

Website: http://www.cgsmedicare.com/jc

IVR Unit: 1.866.238.9650

myCGS Web Portal: http://www.cgsmedicare.com/jc/mycgs/index.html

Customer Service: 1.866.270.4909

Telephone Re-openings: 1.866.813.7878

LCDs and Policy Articles: http://www.cgsmedicare.com/jc/coverage/lcdinfo.html


http://www.cgsmedicare.com/jc

http://www.cgsmedicare.com/jc/mycgs/index.html

http://www.cgsmedicare.com/jc/coverage/lcdinfo.html

Revised: May 2020

Noridian Healthcare SolutionsJurisdiction D Resources

Website: https://med.noridianmedicare.com/web/jddme/

IVR, Supplier Contact Center and Telephone Reopenings: 1.877.320.0390

Noridian Medicare Portal: https://med.noridianmedicare.com/web/jddme/topics/nmp

LCDs and Policy Articles: https://med.noridianmedicare.com/web/jddme/policies/lcd/active


https://med.noridianmedicare.com/web/jddme/

https://med.noridianmedicare.com/web/jddme/topics/nmp

https://med.noridianmedicare.com/web/jddme/policies/lcd/active

Revised: May 2020

Other Contractor Resources Coding - PDAC

• 1.877.735.1326

• http://www.dmepdac.com

National Supplier Clearinghouse

• 1.866.238.9652

• http://www.palmettogba.com/nsc

CEDI

• 1.866.311.9184

• http://www.ngscedi.com/ngs/portal/ngscedi

• E-mail: [email protected]


http://www.dmepdac.com/

http://www.palmettogba.com/nsc

http://www.ngscedi.com/ngs/portal/ngscedi

mailto:[email protected]


Thank you for attending!

Question and Answer


Revised: May 2020

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Revised: May 2020

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Revised: May 2020

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Revised: May 2020

DisclaimerThis presentation was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference.

This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.

The Centers for Medicare & Medicaid Services (CMS) employees; agents, including CGS and its staff; and CMS’ staff make no representation, warranty, or guarantee that this compilation of Medicare information is error free and will bear no responsibility or liability for the results or consequences of the use of this guide. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings.

This presentation may not be recorded.


Documents

A Collaboration Webinar presented by the Nebulizers A/B ...€¦ · Once you are connected to the webinar, ... (CGM) are not enforced • External Infusion Pumps (L33794); • Infusion