Avoid This Billing Pitfall with Your Medicare Part B Nebulizer Solution Claims

Correctly billing Medicare Part B can be tough. The Local Coverage Determinations and associated Policy Articles for each DMEPOS category, along with the Standard Documentation Requirements for All Claims Submitted to DME MACs, are filled with billing and documentation guidelines which suppliers must fully comprehend and follow to avoid claim chargeback. The PAAS National® 2024 DMEPOS Newsline Series is a great starting point for pharmacies to building their comprehension of these unique requirements. Simply keyword search “DMEPOS series” to read these articles in the archives.

A general overview of billing DMEPOS nebulizer solutions can be found in the April Newsline article, 2024 DMEPOS Series #2: Nebulizer Solutions. During recent Targeted Probe and Educate (TPE) audits from DME MAC CGS, PAAS analysts have seen an uptick in discrepant claims due to billing a larger amount than allowed as medically necessary.

Why This is Happening

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Claims are flagged because a beneficiary is on either albuterol, albuterol/ipratropium combination, levalbuterol, or metaproterenol as a rescue or supplemental medication in addition to either formoterol or arformoterol. The presence of formoterol or arformoterol as an active medication for the beneficiary triggers a lower monthly maximum milligrams/month policy limit on the rescue or supplemental medication (i.e., albuterol, albuterol/ipratropium combination, levalbuterol, or metaproterenol).

Inhalation Drugs and SolutionsStandard MaximumReduced Maximum When Beneficiary is Also on Formoterol or Arformoterol
Albuterol465 mg/month78 mg/month
Albuterol/Ipratropium combination186 units/month31 units/month
Levalbuterol232.5 mg/month – 465 units/month39 mg/month – 78 units/month
Metaproterenol2800 mg/month – 280 units/month470 mg/month – 47 units/month

How to Avoid This Pitfall

Pharmacies supplying any one of these four inhalation drugs in the table above should be reviewing all evidence prior to billing the claim to Part B to verify which monthly limit is applicable for the claim; here are several considerations:

  • Review the patient’s medication profile at your pharmacy to see if they are getting any medication with formoterol (e.g., formoterol nebulizer solution [Perforomist®]; budesonide and formoterol inhaler [Symbicort®, BreynaTM]; glycopyrrolate and formoterol inhaler [Bevespi Aerosphere®]; budesonide, glycopyrrolate, and formoterol [Breztri Aerosphere®]; mometasone and formoterol [Dulera®]; etc.) or arformoterol [Brovana®] nebulizer solution
  • Obtain medical records from the prescriber’s office from within 12 months prior to the date of the claim and review the records for any active formoterol or arformoterol
  • Ask the patient or their representative if they are using any prescription products with formoterol or arformoterol

If the investigation to any of the above considerations shows active formoterol or arformoterol, be sure:

  1. The order being billed for one of the four inhalation drugs in the table above falls within the reduced maximum supply limit, or
  2. Contact the prescriber to adjust the order to be within the reduced maximum policy limit, or
  3. Complete an Advanced Beneficiary Notice of Non-Coverage (ABN) prior to dispensing because the claim is not expected to be covered.

PAAS Tips:

  • Refer to the December 2021 Newsline article, Advanced Beneficiary Notice of Non-coverage Changes, for more information about the use of an ABN
  • The Same and Similar tool on the DME MAC website may not be helpful as some of the formoterol-containing items would not be billed to Medicare Part B (but instead, Part D) and because suppliers have 12 months to file a Part B claim, meaning the data may not be up to date

Sara Hathaway, PharmD
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