CurrentEmblemHealthPolicy N/A

NYRx and NYS Medicaid DMEPOS Nebulizers

Defines which nebulizer devices, accessories, and nebulized medications are provided through NYRx (pharmacy) versus DMEPOS providers and which benefit (NYRx or MCO) is responsible; intended for Pharmacy, DMEPOS providers, and MCOs serving New York Medicaid members.

Policy Summary

PayerEmblemHealth

PolicyNYRx and NYS Medicaid DMEPOS Nebulizers

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionRefer to the assignment chart to determine whether a nebulizer device, accessory, or medication is provided by NYRx (pharmacy) or a DMEPOS provider and which program (NYRx or MCO) is responsible for billing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipledevice, accessory, and medication assignments listed

E0570example compressor nebulizer code

A7003–A7015example supply codes

NYstate

Coverage assignments for nebulizers, supplies, and nebulized medications

Coverage assignments

Coverage and billing assignments (who provides the item and which program/payer is responsible):

ALL of the following

Available from: Pharmacy
Medication listed on NYRx List of Reimbursable Drugs (NDC or HCPCS)
Responsible party: NYRx

ALL of the following

Available from: DMEPOS provider
Responsible party: MCO

Policy Summary

PayerEmblemHealth

PolicyNYRx and NYS Medicaid DMEPOS Nebulizers

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Referenced HCPCS and supply codes

Covered HCPCS/Supply CodesHCPCSCovered

E0570F6	Nebulizer (with compressor)
A7015F8	Aerosol mask; used with DME nebulizer
S8100F21	Holding chamber or spacer for use with an inhaler or nebulizer; with a mask
S8101F21	Holding chamber or spacer for use with an inhaler or nebulizer; with a mask
A7005F7	Administration kit; with small volume non- filtered pneumatic nebulizer; non-disposable
A7003	Administration kit; with small volume non- filtered pneumatic nebulizer; disposable
A7004	Small volume nonfiltered pneumatic nebulizer; disposable
A7007	Large volume nebulizer; disposable, unfilled, used with aerosol compressor
E0424F26	30-Day rental: Stationary compressed gaseous oxygen system (includes nebulizer)

Billing source and responsible party assignments — provider actions and responsibilities

Billing Rule

Billing source and responsible party assignments for nebulizer items

Billing source and responsible party assignments for nebulizer items — lists which items are available from Pharmacy vs DMEPOS providers and which party (NYRx or MCO/DMEPOS) is responsible; includes HCPCS/NDC.

Medication used within the nebulizer — Available From: Pharmacy; Responsible Party: NYRx; Drug and/or Supply Codes (NDC or HCPCS): NYRx List of Reimbursable Drugs.
Nebulizer (with compressor) — Available From: DMEPOS provider; Responsible Party: MCO; Drug and/or Supply Codes (HCPCS): E0570F6.
Nebulizer (ultrasonic; large volume) — Available From: DMEPOS provider; Responsible Party: MCO; Drug and/or Supply Codes (HCPCS): (no code specified).
Aerosol mask; used with DME nebulizer — Available From: Pharmacy or DMEPOS provider; Responsible Party: NYRx / DMEPOS; Drug and/or Supply Codes (HCPCS): A7015F8.
Holding chamber or spacer for use with an inhaler or nebulizer; with a mask — Available From: Pharmacy or DMEPOS provider; Responsible Party: NYRx / DMEPOS; Drug and/or Supply Codes (HCPCS): S8100F21, S8101F21.
Administration kit; with small volume non-filtered pneumatic nebulizer, non-disposable — Available From: Pharmacy or DMEPOS provider; Responsible Party: DMEPOS; Drug and/or Supply Codes (HCPCS): A7005F7.

Key definitions and responsibility summaries

nebulizer

DefinitionA nebulizer is a machine that creates a mist from liquid medication for pulmonary delivery, consisting of a base with an air compressor, a holding chamber for the medication, and a tube for delivery.

Primary componentsBase (contains air compressor), holding chamber for medication, and delivery tubing.

PurposeAllows quicker absorption of medication into the lungs by converting liquid medication into an inhalable mist.

Associated needsMembers require both the nebulizer device and the nebulized medication; masks or administration kits may be needed for continued use.

NYRx / DMEPOS / MCO responsibilities

Pharmacy (NYRx) responsibilityMedication used within the nebulizer is available from Pharmacy and the responsible party is NYRx; drugs listed on the NYRx List of Reimbursable Drugs.

DMEPOS providersProvide nebulizer devices (e.g., nebulizer with compressor, ultrasonic large-volume nebulizers) and certain administration kits; examples include E0570F6 for nebulizer with compressor.

Shared/variable itemsAerosol masks and holding chambers/spacers may be available from Pharmacy or DMEPOS providers; responsible parties include NYRx and/or DMEPOS depending on the item (example codes A7015F8, S8100F21, S8101F21).

DMEPOS‑specific responsibilityNon-disposable administration kits with small-volume non-filtered pneumatic nebulizers are available from Pharmacy or DMEPOS providers but the responsible party is DMEPOS (example code A7005F7).