2024 DMEPOS Series #2: Nebulizer Solutions
Many pharmacies struggle with DMEPOS audits due to the complexity in medical billing and the onerous documentation requirements. Medicare Part B suppliers need to be able to produce all the required documentation if audited, and make sure all documentation meets Medicare Part B standards. This DMEPOS series is intended to help you understand these complexities and gather the needed documents.
In particular, you should be able to show the following if audited on nebulizer solutions:
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- Standard Written Order (SWO)
- Medical Records
- Nebulizer solutions are covered by part Medicare Part B only if the patient has a covered chronic pulmonary condition and administration is with a DME nebulizer device
- Continued medical need can be verified by having a:
- Medical record, dated within 12 months of the date of service under review, that shows usage of the item
- Change in prescription dated within 12 months of the date of service under review
- Refill order from the treating practitioner dated within 12 months of the date of service under review
- Covered diagnoses can be found in the Local Coverage Determination (LCD) and Policy Article
- Proof of Delivery
- Proof of Refill Request and Affirmative Response
- Required if delivered or mailed
Common reasons for Medicare B to deny a nebulizer claim include:
- Incomplete or invalid SWO
- Medical records do not indicate a covered diagnosis or contains an incorrect diagnosis for the HCPCS code/drug
- Medical records do not support continuous need
- Medical records are not signed
- Claims billed for more than the Medicare B allowed quantity
- Delivery date does not match date billed
- Delivery address missing for an in-store pick-up
PAAS Tips:
- Monthly limits and a list of covered diagnoses can be found within the LCD and Policy Article
- Review documentation checklist for Jurisdiction A and D
- Review documentation checklists for Jurisdiction B and C
- Nebulizers & Inhalation Drugs: Iloprost and Treprostinil
- Nebulizers & Inhalation Drugs: Large Volume Nebulizers
- Nebulizers & Inhalation Drugs: Small Volume Nebulizers
- Download PAAS’ Proof of Refill Request and Affirmative Response form on the Member Portal where you can document the required information from the beneficiary or their caregiver
- Review the following Newsline articles for additional information:
- August 2023: Standard Written Order and Medicare Part B Audit Risks – New Guidance
- February 2024: DMEPOS Updated Refill Request and Affirmative Response Requirements
Analyst at PAAS National®
I grew up in a family of nurses and other medical professionals but was never interested in the clinic setting. I was drawn to pharmacy because I like to help people and could easily use the knowledge I grew up with to do so. It was a great fit.
I have a Bachelor of Arts in Communications from the University of Wisconsin – Madison. Prior to joining PAAS in 2017, I worked for Walgreens for 19 years.
As an Analyst at PAAS, I really enjoy being able to help independent pharmacies succeed. I have always been a fan of the underdog and am excited to be able to give you the tools you need to take on the giants of the PBM industry.
I have a Bachelor of Arts in Communications from the University of Wisconsin – Madison. Prior to joining PAAS in 2017, I worked for Walgreens for 19 years.
As an Analyst at PAAS, I really enjoy being able to help independent pharmacies succeed. I have always been a fan of the underdog and am excited to be able to give you the tools you need to take on the giants of the PBM industry.
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