Oxygen Modifier Decision Tree

Is the prescribed oxygen portable or stationary?

   

How many liters per minute (LPM) is the beneficiary prescribed?

   

Modifier(s) to Append

  • Initial setups with dates of service prior to April 01, 2023 - RR and KX
  • Initial setups with dates of service on or after April 01, 2023 - RR and N1, N2, or N3 (Coverage criteria met) or Liability Modifier (GA, GY, GZ)

Is the prescribed Oxygen based on an "At Rest" test, or the "Average" of daytime use while at rest and nighttime use (if different)?

   

Modifier(s) to Append

  • Initial setups with dates of service prior to April 01, 2023 - RR, QF, and KX
  • Initial setups with dates of service on or after April 01, 2023 - RR, QF, and N1, N2, or N3 Coverage criteria met) or Liability Modifier (GA, GY, GZ)

Modifier(s) to Append

  • Initial setups with dates of service prior to April 01, 2023 - RR, QB, and KX
  • Initial setups with dates of service on or after April 01, 2023 - RR, QB, and N1, N2, or N3 Coverage criteria met) or Liability Modifier (GA, GY, GZ)

Is the prescribed Oxygen based on an "At Rest" test, or the "Average" of daytime use while at rest and nighttime use (if different)?

   

How many liters per minute (LPM) is the beneficiary prescribed?

       

Modifier(s) to Append

  • Initial setups with dates of service prior to April 01, 2023 - RR, QE, and KX
  • Initial setups with dates of service on or after April 01, 2023 - RR, QE, and N1, N2, or N3 Coverage criteria met) or Liability Modifier (GA, GY, GZ)

Modifier(s) to Append

  • Initial setups with dates of service prior to April 01, 2023 - RR and KX
  • Initial setups with dates of service on or after April 01, 2023 - RR and N1, N2, or N3 (Coverage criteria met) or Liability Modifier (GA, GY, GZ)

Modifier(s) to Append

If Portable Oxygen is Prescribed:

  • Initial setups with dates of service prior to April 01, 2023 - RR, QF, and KX
  • Initial setups with dates of service on or after April 01, 2023 - RR, QF, and N1, N2, or N3 Coverage criteria met) or Liability Modifier (GA, GY, GZ)

 

If No Portable Oxygen is Prescribed:

  • Initial setups with dates of service prior to April 01, 2023 - RR, QG, and KX
  • Initial setups with dates of service on or after April 01, 2023 - RR, QG, and N1, N2, or N3 Coverage criteria met) or Liability Modifier (GA, GY, GZ)

How many liters per minute (LPM) is the beneficiary prescribed?

       

Modifier(s) to Append

  • Initial setups with dates of service prior to April 01, 2023 - RR, QA, and KX
  • Initial setups with dates of service on or after April 01, 2023 - RR, QA, and N1, N2, or N3 Coverage criteria met) or Liability Modifier (GA, GY, GZ)

Modifier(s) to Append

  • Initial setups with dates of service prior to April 01, 2023 - RR and KX
  • Initial setups with dates of service on or after April 01, 2023 - RR and N1, N2, or N3 (Coverage criteria met) or Liability Modifier (GA, GY, GZ)

Modifier(s) to Append

If Portable Oxygen is Prescribed:

  • Initial setups with dates of service prior to April 01, 2023 - RR, QB, and KX
  • Initial setups with dates of service on or after April 01, 2023 - RR, QB, and N1, N2, or N3 Coverage criteria met) or Liability Modifier (GA, GY, GZ)

 

If No Portable Oxygen is Prescribed:

  • Initial setups with dates of service prior to April 01, 2023 - RR, QR, and KX
  • Initial setups with dates of service on or after April 01, 2023 - RR, QR, and N1, N2, or N3 Coverage criteria met) or Liability Modifier (GA, GY, GZ)
 
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