OAR 410-122-0204
Nebulizer

(1)

Indications and limitations of coverage and medical appropriateness:

(a)

Equipment:

(A)

Small volume nebulizer:
(i)
A small volume nebulizer and related compressor may be covered to administer inhalation drugs based on evidence-based clinical practice guidelines;
(ii)
The physician shall have considered use of a metered dose inhaler (MDI) with and without a reservoir or spacer device and decided that, for medical reasons, the MDI was not sufficient for the administration of needed inhalation drugs.

(B)

Large volume nebulizer:
(i)
A large volume nebulizer (A7017), related compressor (E0565 or E0572), and water or saline (A4217 or A7018) may be covered when it is medically appropriate to deliver humidity to a client with thick, tenacious secretions, who has cystic fibrosis, bronchiectasis, a tracheostomy, or a tracheobronchial stent;
(ii)
Combination code E0585 will be covered for the same indications as in (1)(a)(B)(i);

(C)

The Division of Medical Assistance Programs (Division) will consider other uses of compressors/generators individually on a case-by-case basis to determine their medical appropriateness, such as a battery powered compressor (E0571);

(b)

Accessories:

(A)

A large volume pneumatic nebulizer (E0580) and water or saline (A4217 or A7018) are not separately payable and may not be separately billed when used for clients with rented home oxygen equipment;

(B)

The Division does not cover use of a large volume nebulizer, related compressor/generator, and water or saline when used predominately to provide room humidification;

(C)

A non-disposable unfilled nebulizer (A7017 or E0585) filled with water or saline (A4217 or A7018) by the client or caregiver is an acceptable alternative to the large volume nebulizer when used as indicated in (1)(a)(B)(i) of this rule;

(D)

Kits and concentrates for use in cleaning respiratory equipment are not covered;

(E)

Accessories are separately payable if the related aerosol compressor and the individual accessories are medically appropriate. The following table lists each covered compressor/generator and its covered accessories. Other compressor/generator/accessory combinations are not covered;

(F)

Compressor/Generator (Related Accessories): E0565 (A4619, A7006, A7010, A7011, A7012, A7013, A7014, A7015, A7017, A7525, E1372); E0570 (A7003, A7004, A7005, A7006, A7013, A7015, A7525); E0571 (A7003, A7004, A7005, A7006, A7013, A7015, A7525); E0572 (A7006, A7014); E0585 (A4619, A7006, A7010, A7011, A7012, A7013, A7014, A7015, A7525);

(G)

This array of accessories represents all possible combinations, but it may not be appropriate to bill any or all of them for one device;

(H)

Table 122-0204-1 lists the usual maximum frequency of replacement for accessories. The Division will not cover claims for more than the usual maximum replacement amount unless the request has been prior approved by the Division before dispensing. The provider shall submit requests for more than the usual maximum replacement amount to the Division for review.

(2)

Coding guidelines:

(a)

Accessories:

(A)

Code A7003, A7005, and A7006 include the lid, jar, baffles, tubing, T-piece, and mouthpiece. In addition, code A7006 includes a filter;

(B)

Code A7004 includes only the lid, jar, and baffles;

(C)

Code A7012 describes a device to collect water condensation, which is placed in line with the corrugated tubing, used with a large volume nebulizer;

(D)

Code E0585 is used when a heavy-duty aerosol compressor (E0565), durable bottle type large volume nebulizer (A7017), and immersion heater (E1372) are provided at the same time. If all three items are not provided initially, the separate codes for the components would be used for billing;

(E)

Code A7017 is billed for a durable, bottle type nebulizer when it is used with an E0572 compressor or a separately billed E0565 compressor;

(F)

Code A7017 may not be separately billed when an E0585 system is also being billed. Code E0580 (Nebulizer, durable, glass or autoclavable plastic, bottle type, for use with regulator or flow meter) describes the same piece of equipment as A7017 but shall only be billed when this type of nebulizer is used with a client-owned oxygen system.

(b)

Equipment:

(A)

In this policy, the actual equipment (i.e., electrical device) will generally be referred to as a compressor (when nebulization of liquid is achieved by means of air flow). The term nebulizer is generally used for the actual chamber in which the nebulization of liquid occurs and is an accessory to the equipment. The nebulizer is attached to an aerosol compressor in order to achieve a functioning delivery system for aerosol therapy;

(B)

Code E0565 describes an aerosol compressor, which can be set for pressures above 30 psi at a flow of 6-8 L/m and is capable of continuous operation;

(C)

A nebulizer with compressor (E0570) is an aerosol compressor, which delivers a fixed, low pressure and is used with a small volume nebulizer. It is only AC powered;

(D)

A portable compressor (E0571) is an aerosol compressor, which delivers a fixed, low pressure and is used with a small volume nebulizer. It shall have battery or DC power capability and may have an AC power option;

(E)

A light duty adjustable pressure compressor (E0572) is a pneumatic aerosol compressor that can be set for pressures above 30 psi at a flow of 6-8 L/m but is capable only of intermittent operation.

(3)

Documentation requirements:

(a)

When billing for an item in Table 122-0204, medical records shall corroborate that all criteria in this rule are met;

(b)

When billing for quantities of supplies greater than those described in Table 122-0204-1 as the usual maximum amounts, there shall be clear documentation in the client’s medical records corroborating the medical appropriateness of the current use;

(c)

When a battery powered compressor (E0571) is dispensed, supporting documentation that justifies the medical appropriateness shall be on file with the durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) provider;

(d)

The DMEPOS provider shall maintain these medical records and make them available to the Division upon request.

(4)

Table 122-0204-1.

(5)

Table 122-0204-2.
[ED. NOTE: Table referenced is available from the agency.]
[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

Source: Rule 410-122-0204 — Nebulizer, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-122-0204.

410‑122‑0010
Definitions 410‑122‑0020
Orders 410‑122‑0040
Prior Authorization 410‑122‑0080
Conditions of Coverage, Limitations, and Restrictions 410‑122‑0090
Face-to-Face Encounter Requirements (for Fee-For-Service Clients) 410‑122‑0180
Healthcare Common Procedure Coding System Level II Coding 410‑122‑0182
Legend 410‑122‑0184
Repairs, Servicing, Replacement, Delivery, and Dispensing 410‑122‑0186
Payment Methodology 410‑122‑0188
DMEPOS Rebate Agreements 410‑122‑0200
Pulse Oximeter for Home Use 410‑122‑0202
Positive Airway Pressure (PAP) Devices for Adult Obstructive Sleep Apnea 410‑122‑0203
Oxygen and Oxygen Equipment 410‑122‑0204
Nebulizer 410‑122‑0205
Respiratory Assist Devices 410‑122‑0206
Intermittent Positive Pressure Breathing 410‑122‑0207
Respiratory Supplies 410‑122‑0208
Suction Pumps 410‑122‑0209
Tracheostomy Care Supplies 410‑122‑0210
Ventilators 410‑122‑0211
Cough Stimulating Device 410‑122‑0220
Pacemaker Monitor 410‑122‑0240
Apnea Monitors for Infants 410‑122‑0250
Breast Pumps 410‑122‑0260
Home Uterine Monitoring 410‑122‑0280
Heating/Cooling Accessories 410‑122‑0300
Light Therapy 410‑122‑0320
Manual Wheelchair Base 410‑122‑0325
Power Wheelchair Base 410‑122‑0330
Power-Operated Vehicle 410‑122‑0340
Wheelchair Options/Accessories 410‑122‑0360
Canes and Crutches 410‑122‑0365
Standing and Positioning Aids 410‑122‑0375
Walkers 410‑122‑0380
Hospital Beds 410‑122‑0400
Pressure Reducing Support Surfaces 410‑122‑0420
Hospital Bed Accessories 410‑122‑0475
Therapeutic Shoes for Diabetics 410‑122‑0510
Osteogenesis Stimulator 410‑122‑0515
Neuromuscular Electrical Stimulator (NMES) 410‑122‑0520
Glucose Monitors and Diabetic Supplies 410‑122‑0525
External Insulin Infusion Pump 410‑122‑0540
Ostomy Supplies 410‑122‑0560
Urological Supplies 410‑122‑0580
Bath Supplies 410‑122‑0590
Patient Lifts 410‑122‑0600
Toilet Supplies 410‑122‑0620
Miscellaneous Supplies 410‑122‑0625
Surgical Dressing 410‑122‑0630
Incontinent Supplies 410‑122‑0640
Eye Prostheses 410‑122‑0655
External Breast Prostheses 410‑122‑0658
Gradient Compression Stockings/Sleeves 410‑122‑0660
Orthotics and Prosthetics 410‑122‑0662
Ankle-Foot Orthoses and Knee-Ankle-Foot Orthoses 410‑122‑0678
Dynamic Adjustable Extension/Flexion Device 410‑122‑0680
Facial Prostheses 410‑122‑0700
Negative Pressure Wound Therapy Pumps 410‑122‑0720
Pediatric Wheelchairs
Last Updated

Jun. 8, 2021

Rule 410-122-0204’s source at or​.us