Check New Neb Med Changes Twice!

Have you been keeping up?

Medicare has made some significant changes to the codes you must use to bill for nebulizer medications. The codes used to bill for dispensing fees have changed. And there has also been a change in the code for DuoNeb and the way the billing units are calculated.

The new code for DuoNeb is J7620 (albuterol up to 2.5mg and ipratropium bromide up to 0.5mg, non-compounded inhalation solution administered through DME). This code change went into effect on Jan. 1, 2006.

Using the new code, one vial is equal to one billing unit. In comparison, the old code for DuoNeb (J7616) was billed out at two billing units per vial. Of course, the old definition considered a vial that held twice as much medicine (albuterol up to 5mg and ipratropium bromide up to 1mg, compounded inhalation solution administered through DME).

With the code change, however, you still should not use any of the modifiers (KO, KP or KQ) when billing DuoNeb. But if you are still compounding using J7613 (albuterol unit dose preparation) and J7644 (ipratropium bromide unit dose preparation), you need to make sure the modifiers (KO, KP and KQ) are added as necessary in order to minimize the cost to the Medicare beneficiary.

You also need to keep your billing staff updated on CMS’ quarterly drug price changes, as these may have an effect on how the modifiers are used. During the second quarter of 2005, the use of the KO and KP modifiers actually changed due to pricing changes between these two drugs, so make certain your personnel always have the most recent price for the date of service you are billing.

The dispensing fee codes also have been overhauled as of Jan. 1, 2006. There are now three codes used to bill a dispensing fee:

• Code Q0513 replaces code G0371 for the pharmacy dispensing fee for inhalation drugs per 30 days, and the allowable has been changed to $33.
• Code Q0514 replaces code G0374 for the pharmacy dispensing fee for inhalation drugs per 90 days, and the allowable is now $66.
• The biggest change, though, is the addition of code G0333. This code should now be used for the initial 30-day supply of pharmacy inhalation drugs, and the allowable is set at $57 — but the new code is billed only for the initial claim of a new recipient.

After the initial month, you would bill the Q0513 or the Q0514, depending on how many months’ supply you are putting out. Realize, of course, that if the beneficiary has a prior claim that has been paid to any supplier for inhalation drugs, your initial G0333 dispensing fee will be downcoded to a Q0513.

There are also some other items to be aware of. For a refill prescription, Medicare will not allow payment of the dispensing fee any sooner than seven days prior to the end of usage of the current 30- or 90-day script for which a dispensing fee was previously paid.

Also keep in mind that an inhalation drug supplier will not be allowed more than 12 months of dispensing fees per beneficiary per year. If you are providing a 90-day supply to any of your patients, make sure you understand that Medicare will only pay one dispensing fee — regardless of the number of pharmacies used by a beneficiary.

The billing of inhalation drugs has always been a little tricky, especially when it comes to the use of the KO, KP and KQ modifiers and the calculation of billing units per vial.

Just remember to keep up with any changes, do your calculations twice, make sure you are using the correct fee schedule for the DOS you are billing, and put the correct dispensing fee code with your claim.

Jane Bunch is vice president, HME consulting, for Atlanta-based CareCentric. A reimbursement specialist, Bunch delivers educational seminars worldwide, helps develop corporate compliance plans and serves as a consultant for fraud and abuse cases. She can be reached at 770/366-0644 or via e-mail at [email protected].