Suppliers are no doubt busy with the seasonal influx of patients suffering with respiratory illnesses. Fortunately, the DME MACs added several new covered diagnoses to the Nebulizer Policy Article that, effective October 1, 2023, clear a reimbursement path for those in need.

Next Episode: Thursday, August 22, 2024

COVID-19

The DME MACs added three new diagnoses for COVID-19, COVID-related pneumonia, and post-COVID complications. They include:

  • U07.1 COVID-19.
  • U09.9 Post COVID-19 condition unspecified.
  • J12.82 Pneumonia due to COVID-19.

Even though the public health emergency (PHE) ended last year, these additions are important because COVID-19 is clearly going to be part of the cold and flu season lexicon of the future.

COVID-Related Nebulizer Denials Between May 1 and October 1, 2023

Because of the gap between the end of the PHE on May 12 and the implementation date of the policy article update, suppliers may have received denials for nebulizers provided to COVID-19 patients during that period. We recommend appealing denied claims on the grounds of individual patient medical necessity when medical records establish the need for treatment intervention. Despite the timing difference, this policy article change codifies the precedent established by the medical community during the pandemic for using nebulizer treatments as an effective COVID-19 treatment.

Other Diagnosis Codes Added

In addition to the COVID-related diagnosis codes added to the policy article, the update also includes nebulizer coverage for the following:

  • J15.61 Acinetobacter baumannii pneumonia.
  • J15.69 Gram-negative bacteria pneumonia.
  • J44.89 Other specified COPD.
  • J44.81 Bronchiolitis obliterans and bronchiolitis obliterans syndrome.

Be sure to circulate this information with intake and billing teams to ensure they are considering the new diagnoses when evaluating medical records and preparing health insurance claims.