RETIRED - Revised Billing Instruction - Oxygen Q Modifiers and Medical Documentation - JD DME

Joint DME MAC Article

On April 26, 2018, the DME MACs published an article entitled "Billing Instruction-Oxygen CMN Question 5 - Revised" with supplier guidance on use of new oxygen "Q" modifiers. The article stated that for use of the QB and QR modifiers, if a beneficiary is prescribed a single flow rate that doesn't encompass a full 24 hours, an average calculation is required with the unaccounted for portion of the 24 hour period set equal to "0."  This instruction is rescinded. 

For beneficiaries with a single prescribed flow rate that doesn't encompass a full 24 hours, an average is NOT required using "0" for the unaccounted for portion of the 24 hour period.  The information below from the original article has been modified to reflect this guidance (see QB and QR modifier information below).  The remainder of the article is unchanged.

Suppliers cannot bill for oxygen using the "Q" modifier until compliance with the regulations at 42 CFR Section 414.226(e) has been documented in the patient's record. That regulation stipulates that:

1. If prescribed flow rate is different for stationary versus portable, the flow rate for stationary is used.
2. If prescribed flow rate is different for the patient at rest versus the patient with exercise, the flow rate at rest is used.
3. If prescribed flow rate is different for nighttime versus daytime use, the flow rates are averaged.

The information below is intended to assist suppliers with determining if the documentation in the beneficiary's medical record is in compliance with this regulation.

Modifier QE - PRESCRIBED AMOUNT OF STATIONARY OXYGEN WHILE AT REST IS LESS THAN 1 LITER PER MINUTE (LPM)

• If prescribed flow rate is <1 LPM, examine the record for an "at rest" qualifying test value on room air.

Modifier QF - PRESCRIBED AMOUNT OF STATIONARY OXYGEN WHILE AT REST EXCEEDS 4 LITERS PER MINUTE (LPM) AND PORTABLE OXYGEN IS PRESCRIBED

• If prescribed flow rate is >4 LPM, examine the record for an "at rest" qualifying test value on room air taken at 4 LPM.

Modifier QG - PRESCRIBED AMOUNT OF STATIONARY OXYGEN WHILE AT REST IS GREATER THAN 4 LITERS PER MINUTE (LPM)

• If prescribed flow rate is >4 LPM, examine the record for an "at rest" qualifying test value on room air taken at 4 LPM.
• DO NOT use a "with exercise" qualifying test and associated flow rate to determine the use of modifier QG.

Modifier QA - PRESCRIBED AMOUNTS OF STATIONARY OXYGEN FOR DAYTIME USE WHILE AT REST AND NIGHTTIME USE DIFFER AND THE AVERAGE OF THE TWO AMOUNTS IS LESS THAN 1 LITER PER MINUTE (LPM)

• If prescribed flow rate is <1 LPM, examine the record for a daytime "at rest" qualify test value on room air and a prescribed flow rate (if applicable) and a "nocturnal" qualifying test value and prescribed flow rate.
  • If both a flow rate for daytime rest use and flow rate for nocturnal use are documented, calculate the average of the two values (standard arithmetic rounding rules apply).  If the result is an average flow rate <1LPM, use the QA modifier.

Modifier QB - PRESCRIBED AMOUNTS OF STATIONARY OXYGEN FOR DAYTIME USE WHILE AT REST AND NIGHTTIME USE DIFFER AND THE AVERAGE OF THE TWO AMOUNTS EXCEEDS 4 LITERS PER MINUTE (LPM) AND PORTABLE OXYGEN IS PRESCRIBED; and,

Modifier QR - PRESCRIBED AMOUNTS OF STATIONARY OXYGEN FOR DAYTIME USE WHILE AT REST AND NIGHTTIME USE DIFFER AND THE AVERAGE OF THE TWO AMOUNTS IS GREATER THAN 4 LITERS PER MINUTE (LPM)

• If prescribed flow rate is >4 LPM, examine the record for a daytime "at rest" qualify test value on room air and a prescribed flow rate (if applicable) and a "nocturnal" qualifying test value and prescribed flow rate.
  • If both a flow rate for daytime at rest use and flow rate for nocturnal use are documented, calculate the average of the two values (standard arithmetic rounding rules apply).  If the result is an average flow rate >4LPM, use the QB modifier if both stationary and portable are prescribed.
  • If both a flow rate for daytime at rest use and flow rate for nocturnal use are documented, calculate the average of the two values (standard arithmetic rounding rules apply).  If the result is an average flow rate >4LPM, use the QR modifier if only stationary is prescribed.
  • If there is a single flow rate for nocturnal use only, no average is required.
    • If the flow rate is >4LPM, use the QB modifier if both stationary and portable are prescribed.
    • If the flow rate is >4LPM, use the QR modifier if only stationary is prescribed.

For all "Q" modifiers, in no case can a prescribed flow rate for exercise be used, either alone or in conjunction with a prescribed flow rate for nighttime use, to determine whether or not a low (less than 1 LPM), high (more than 4 LPM), or other (more than 1 LPM but less than 4 LPM) prescribed flow rate applies for Medicare payment purposes. 

Since the "Q" modifiers submitted on the claim will be used in determining the applicability of the volume adjustment payment, suppliers cannot bill for oxygen until compliance with the regulations has been documented in the patient's record. Oxygen volume adjustment claims where the medical record is not in compliance with regulatory policy constitutes fraudulent billing and may be subject to penalties.

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