by Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
February 24th, 2016
The ICD-10-CM code describing the condition necessitating nebulizer therapy must be included on each claim for equipment, accessories, and/or drugs.
When ever a unit dose code is billed, it must have a KO, KP, or KQ modifier. (Exception: The KO, KP, and KQ modifiers should not be used with code J7620.)
When billing miscellaneous equipment or accessories (E1399), the claim must include:
- Clear description of item being billed, the manufacturer, and the model name/number, if applicable.
When billing a not otherwise classified drug (J7699), the claim must include:
- Detailed order information as described above and a clear statement of the number of ampules/bottles of solution dispensed.
- The KX modifier must be added to codes E0574, J7686, K0730, and Q4074 only if all the coverage criteria noted above have been met.
- When there is an expectation of a medical necessity denial, the GA modifier must be added to the code if a valid Advance Beneficiary Notice (ABN) has been obtained or a GZ modifier if a valid ABN has not been obtained.
The order for any drug must clearly specify the type of solution to be dispensed and the administration instructions for that solution. The type of solution is described by a combination of:
- Name of the drug and the concentration of the drug in the dispensed solution and the volume of solution in each container, OR
- Name of the drug and the number of milligrams/grams of drug in the dispensed solution and the volume of solution in that container.
Dispensing fees:
- One (1) unit of G0333 is covered for the initial 30 day supply of covered inhalation drug(s) regardless of the number of drugs dispensed, number of shipments, or number of pharmacies used by the beneficiary during that time.
- G0333 is a once in a lifetime fee and only applies to beneficiaries using inhalation drugs for the first time.
- Only one of the following will be paid for covered inhalation drugs regardless of the number of drugs dispensed, the number of shipments, or the number of pharmacies used by the beneficiary during that time period: an initial dispensing fee (G0333), a 30 day dispensing fee (Q0513), or a 90 day dispensing fee (Q0514).
- For refill prescription, payment of a dispensing fee will be allowed no sooner than 14 days before the end of usage for the current 30 day (Q0513) or 90 day (Q0514) period for which a dispensing fee was previously paid.
- Payment will be made for no more than 12 months of dispensing fees per beneficiary per 12 month period.
- Dispensing fee must be billed on the same claim as the inhalation drugs.
References: L11488, PA A24942 (prior to 10/01/2015); L33370, A52466 (on/after 10/01/2015)
References:
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