Common CERT Oxygen Errors

The Comprehensive Error Rate Testing (CERT) Review Contractor reviewed oxygen claims, both stationary and portable codes. Noridian has gathered the top CERT error comments and listed documentation that may assist in preventing or eliminating errors.

CERT Error Comment: Missing the treating physician's clinical records to support beneficiary's condition that requires oxygen use and that the beneficiary continues to need and use supplemental home oxygen proximal to billed date of service (DOS). This information can be from 12 months prior to 6 months after billed date of service.

Examples of appropriate documentation that would qualify for continued need:

  • A recent order by the treating physician for refills; or
  • A recent change in prescription; or
  • A properly completed Certificate of Medical Necessity (CMN) or DME Information Form (DIF) with a specified length of need
  • Timely documentation in the beneficiary's medical record showing usage of the item

Timely documentation is defined as a record in the preceding 12 months unless otherwise specified in the respective policy.

Examples of appropriate documentation that would qualify for continued use:

  • Timely documentation in the beneficiary's medical record showing usage of the item, related option/accessories and supplies; or
  • Supplier records documenting the request for refill/replacement of supplies in compliance with the Refill Documentation Requirements (This is deemed to be sufficient to document continued use for the base item, as well.); or
  • Supplier records documenting beneficiary confirmation of continued use of a rental item

Continued need and continued use are two different documentation requirements the supplier would need to meet in this criteria.

CERT Error Comment: Missing the signed and dated order from the physician that reflects the change in oxygen liter flow rate.

Examples of appropriate documentation would include:

  • A valid order from the physician that clearly states the change in oxygen liter flow rate.
  • A Revised CMN is required when a beneficiary changes from one liter flow category to another (i.e. from 3 lpm to 6 lpm). This revised CMN must be maintained in the supplier records and provided upon request.

CERT Error Comment: Missing a copy of the qualifying oxygen saturation study that applies to the conditions stated on the recertification CMN for the oxygen concentrator.

When responding to a request from CERT, it is imperative to include a valid copy of the qualifying oxygen saturation study that matches the information on the CMN. Please refer to the oxygen Local Coverage Determination (LCD) for testing specifications.

CERT Error Comment: Missing the treating physician's re-evaluation within 90 days of the recertification CMN supporting the beneficiary's lung disease or hypoxia-related symptoms that improve with oxygen therapy.

Prior to Recertification the coverage criteria for home oxygen therapy requires a physician face to face visit documenting the re-evaluation within 90 days of recertification and that the beneficiary shows improvement while on oxygen therapy:

Examples of appropriate comments within the beneficiary's medical records would include:

  • Beneficiary continuing to use oxygen;
  • Saturation improved;
  • Less shortness of breath, dyspnea improved;
  • Color of nail beds improved; beneficiary able to complete MRADL's with less effort and dyspnea;
  • Beneficiary able to care for self with less breaks and less shortness of breath;
  • Beneficiary able to walk to bathroom without dyspnea which is an improvement over a year ago;
  • Beneficiary heartrate and respiratory rate back to more normal levels with activity after oxygen use this past year.
  • 12 months after Initial Certification, (i.e., with the thirteenth month's claim) for Group I
  • 3 months after Initial Certification, (i.e., with the fourth month's claim) for Group II

Recertification CMN is Required:

  • 12 months after Initial Certification, (i.e., with the thirteenth month's claim) for Group I
  • 3 months after Initial Certification, (i.e., with the fourth month's claim) for Group II

Testing and Visit Requirements:
Recertification following initial certification situations 1 and 2

  • For beneficiaries initially meeting Group I criteria, the most recent qualifying blood gas study prior to the thirteenth month of therapy must be reported on the Recertification CMN.
  • For beneficiaries initially meeting Group II criteria, the most recent blood gas study that was performed between the 61st and 90th day following Initial Certification must be reported on the Recertification CMN. If a qualifying test is not obtained between the 61st and 90th day of home oxygen therapy but the beneficiary continues to use oxygen and a test is obtained at a later date, if that test meets Group I or II criteria, coverage would resume beginning with the date of that test.
  • For beneficiaries initially meeting group I or II criteria, the beneficiary must be seen and re-evaluated by the treating physician within 90 days prior to the date of any Recertification. If the physician visit is not obtained within the 90-day window but the beneficiary continues to use oxygen and the visit is obtained at a later date, coverage would resume beginning with the date of that visit.

 

Last Updated Jun 25, 2018