Nebulizer Tips for Providers and Their Coders

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  • May 10, 2019
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Nebulizer Tips for Providers and Their Coders

If your provider is ordering nebulizers and the drugs used in them for their patients, here are things  in the documentation that will help prevent a resubmission to Medicare and ease medical coding.

CMS Wants Nebulizer Necessity

The Centers for Medicare & Medicaid Services (CMS) recently released an MLN fact sheet that helps clarify what’s needed to successfully bill for a prescribed nebulizer.  According to CMS, nebulizer claims must include the following:

  • A Written Order Prior to Delivery (WOPD), which must be a 5 Element Order (5EO) and include all of 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

Medicare warns it will deny items delivered by a supplier without first receiving the completed order.
Be sure establish initial justification for medical need when ordering the items being prescribed.  Create beneficiary medical records demonstrating that the item is reasonable and necessary prior to, or at the time of, the creation of the initial prescription.
Examples of appropriate documentation that qualify for continued medical necessity include initial justification and the following items:

  1. A recent order by the treating physician for refills
  2. A recent change in prescription
  3. Documentation in the 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:

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  1. Beneficiary’s name
  2. Delivery address
  3. 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
  4. A description of the items being delivered. The description can be either a narrative description (for example, a lightweight wheelchair base), a HCPCS Level II code, the long description of a HCPCS Level II code, or a brand name/model number
  5. Quantity delivered
  6. Date delivered
  7. Evidence of delivery
Brad Ericson
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About Has 394 Posts

Brad Ericson, MPC, CPC, COSC, is a seasoned healthcare writer and editor. He directed publishing at AAPC for nearly 12 years and worked at Ingenix for 13 years and Aetna Health Plans prior to that. He has been writing and publishing about healthcare since 1979. He received his Bachelor's in Journalism from Idaho State University and his Master's of Professional Communication degree from Westminster College of Salt Lake City.

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