DME
MAC Jurisdiction C Site LinksApril 14, 2008
Nebulizers - Brovana and Perforomist - Instructions for New HCPCS Codes, April 2008
New HCPCS codes have been created for Perforomist (formoterol, Q4099), effective April 1, 2008, and Brovana (arformoterol, J7605), effective January 1, 2008.
J7605 Arformoterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose form, 15 micrograms
Q4099 Formoterol fumarate, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose form, 20 micrograms
In August 2007, an article, Nebulizers – Perforomist and Brovana – Coverage Criteria and Billing Instructions, was published providing guidance on coverage and coding of these drugs. The updated article below includes instructions for each new product.
Coverage Criteria
FDA-approved inhalation solutions of formoterol (Q4099) or arformoterol (J7605) are covered when the following criteria are met:
- It is medically necessary for the management of chronic obstructive pulmonary disease (ICD-9 diagnosis codes 491.0-492.8, 496); and
- The patient has a documented history of routine use of at least four doses per day of an FDA-approved albuterol or metaproterenol inhalation solution or at least three doses per day of an FDA-approved levalbuterol inhalation solution.
If the above coverage criteria are not met, formoterol and arformoterol will be denied as not medically necessary.
Formoterol and arformoterol are administered using a pneumatic compressor (E0570, E0571) and a small volume nebulizer (A7003, A7004, A7005).
A maximum of two vials of formoterol (20 micrograms each) or two vials of arformoterol (15 micrograms each) are covered per day.
Short-acting beta-adrenergic agonists (SABAs) may be covered as
rescue/supplemental medication in addition to formoterol or arformoterol.
However, when formoterol or arformoterol is used, the maximum amount
of SABA inhalation solutions that will be covered is an average of
one dose per day (31 doses per month).
Coding and Billing Guidelines
When submitting claims for formoterol or arformoterol, use the following
codes:
- Q4099 for Perforomist (formoterol), effective April 1, 2008
- J7605 for Brovana (arformoterol), effective January 1, 2008
Append the KO modifier, when submitting claims for formoterol or arfomoterol.
A KX modifier must be appended to these codes, only when the coverage criteria stated above have been met.
When billing for Perforomist, 1 unit of service = 1 vial (20 micrograms).
When billing for Brovana, 1 unit of service = 1 vial (15 micrograms).
Also, remember that the LCD requires that an ICD-9 code, describing the condition, which necessitates nebulizer therapy, must be included on each claim for equipment, accessories, and/or drugs.
Refer to the Nebulizers LCD and Policy Article for additional information on coverage, coding, and billing of inhalation solutions.
The Nebulizers policy has been revised to incorporate this information.
