Billing & Coding

Help ensure proper reimbursement for your Medicare Part B patients

Understanding how to bill Medicare Part B payers

New Medicare Part B patients will need 2 separate prescriptions and a detailed written order.* Patients who have never been prescribed a nebulized product will need the following:

1A prescription for YUPELRI may have the following specifications:

  • Dosing instructions
  • “Via standard jet nebulizer"
  • Quantity to be dispensed
  • Number of refills
  • J-CODE J7677
  • Applicable ICD-10 code: J40-J44.9†
  • Covered through the Part B Medical benefit

2If a nebulizer is needed, a prescription for the standard jet nebulizer may include‡:

  • Compressor
  • Administration set
  • Applicable ICD-10 code: J40-J44.9†
  • Covered through the Part B Medical benefit

3Detailed written order30

Medicare requires a physician to document that a face-to-face encounter/examination with the patient, detailing the treatment and/or evaluation of a condition that supports the need for the nebulizer, occurred within the 6 months prior to the written order for a nebulizer.

*This is not a guarantee of coverage. Site of Care will determine coverage. Check with your patient's insurance provider for coverage rules and restrictions. In certain limited instances, YUPELRI may be covered through a patient's Medicare Part D pharmacy benefit.

†Other codes may apply.

‡DME suppliers may require additional documentation.

Number of Billable Units

The billing unit for YUPELRI is 1 mcg. Each vial contains 175 mcg/3 mL of YUPELRI. Based on the prescribing information, patients should use one vial of YUPELRI once daily. Billing should be based on actual units dispensed.

If the units provided exceed the size of the units field, or require more characters to report than spaces available in the format, repeat the HCPCS or NDC code on multiple lines until all units can be reported.31

Example:
A 30-day supply would result in dispensing of 175 mcg per day, resulting in 5,250 units to be billed for a 30-day supply.

Payer Documentation Checklist

Use the following checklist to minimize the risk of claims denials.

  • Beneficiary's name or Medicare Beneficiary Identifier (MBI)
  • Order date
  • Description of the item
  • Any changes or corrections have been initialed/signed and dated by the ordering practitioner
  • Treating practitioner's signature on the written order meets CMS Signature Requirements
  • Specify:
    • YUPELRI inhalation solution 175 mcg/3 mL vial1
    • 1 vial QD via standard jet nebulizer
    • Quantity to be dispensed
    • Number of refills
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