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:

  1. Incomplete or invalid SWO
  2. Medical records do not indicate a covered diagnosis or contains an incorrect diagnosis for the HCPCS code/drug
  3. Medical records do not support continuous need
  4. Medical records are not signed
  5. Claims billed for more than the Medicare B allowed quantity
  6. Delivery date does not match date billed
  7. Delivery address missing for an in-store pick-up

PAAS Tips:

Jenevra Azzopardi, CPhT