Oxygen - JA DME
Oxygen
Coverage
- Home Use of Oxygen (240.2) National Coverage Determination (NCD)
- Oxygen and Oxygen Equipment Local Coverage Determination (LCD)
- Oxygen and Oxygen Equipment Policy Article
Documentation
- Standard Documentation Requirements for All Claims Submitted to DME MACs
- Clinician Checklist High Liter Flow Oxygen [PDF] - Checklist to assist clinicians with coverage and documentation requirements
- Clinician Letter - Continued Medical Necessity [PDF] - Clinician directed letter that reminds them that ongoing need for and use of a DMEPOS item must be documented in the patient's medical record
- Clinician Letter - Home Oxygen Initial Qualification Testing [PDF] - Clinician directed letter that reviews blood oxygen testing requirements
- Oxygen and Oxygen Equipment Documentation Checklist [PDF] - Checklist to ensure suppliers gather all required documentation
Oxygen Q Modifiers
Reminder: Both the portable and stationary should have the same Q Modifiers appended to the claim lines.
| Codes | Modifiers | Liters Per Minute (LPM) | Fee Schedule |
|---|---|---|---|
| Stationary: (e0424, e0425, e0439, e0440, e1353, e1390, e1391, e1405, e1406) | QE - Prescribed amount of stationary oxygen while at rest is less than 1 liter per minute 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) | Less than 1 and is ONLY for stationary | .5 of the fee schedule amount. |
| Stationary: (e0424, e0425, e0439, e0440, e1353, e1390, e1391, e1405, e1406) | QG - Prescribed amount of stationary oxygen while at rest is greater than 4 liters per minute (LPM) 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) | Greater than 4 and patient is ONLY receiving stationary | 1.5 times fee schedule |
| Stationary: (e0424, e0425, e0439, e0440, e1353, e1390, e1391, e1405, e1406) Portable: (E0430, E0431, E0433, E0434, E0435, E1392, K0738) | QF - Prescribed amount of stationary oxygen while at rest exceeds 4 liters per minute (LPM) and portable oxygen is prescribed QB - Prescribed amounts of stationary oxygen for daytime used 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 | Greater than 4 and the beneficiary is receiving both stationary and portable | Stationary: Fee Schedule Portable: .5 of the fee for the stationary or the portable amount whichever is greater |
Oxygen N Modifiers
The Centers for Medicare and Medicaid Services (CMS) announced the new N-modifiers for oxygen. The 3 new modifiers for home oxygen use under national coverage determination (NCD) 240.2 and the DME MAC Oxygen and Oxygen Equipment Local Coverage Determination (LCD) and LCD-related Policy Article (PA) were created to indicate the appropriate treatment regimen and presence of supporting documentation for each Medicare patient oxygen therapy group:
LCD Group I: modifier N1 (NCD Section B)
LCD Group II: modifier N2 (NCD Section B)
LCD Group III: modifier N3 (NCD Section D)
The new modifiers are effective January 1, 2023 and are required for initial setups with dates of service on or after April 01, 2023.
| Codes | Modifiers | Description |
|---|---|---|
| Stationary: (e0424, e0425, e0439, e0440, e1353, e1390, e1391, e1405, e1406) Portable: (E0430, E0431, E0433, E0434, E0435, E1392, K0738) | N1 | Group 1 Coverage Criteria: Effective dates of service 01/01/2023 and after. Required for initial Dates of Service 4/01/2023 and after. |
| Stationary: (e0424, e0425, e0439, e0440, e1353, e1390, e1391, e1405, e1406) Portable: (E0430, E0431, E0433, E0434, E0435, E1392, K0738) | N2 | Group II Coverage Criteria: Effective dates of service 01/01/2023 and after. Required for initial Dates of Service 4/01/2023 and after. |
| Stationary: (e0424, e0425, e0439, e0440, e1353, e1390, e1391, e1405, e1406) Portable: (E0430, E0431, E0433, E0434, E0435, E1392, K0738) | N3 | Group III Coverage Criteria: Effective dates of service 01/01/2023 and after. Required for initial Dates of Service 4/01/2023 and after. |
Tips
| Topic | Detail |
|---|---|
| FAQ - Oxygen | View collaborative Noridian and CGS FAQ for oxygen policy changes January 1, 2023 |
| Rounding Rules | Instructions for reporting test results and determining coverage when the values are not whole numbers are provided. This most often occurs for oxygen saturation results (either arterial blood gas or pulse oximetry) and sleep tests where the apnea/hypopnea index (AHI) or respiratory disturbance index (RDI) results are expressed with a decimal place. In both of these instances, standard numerical rounding rules apply. For example, consider a sleep test where the AHI is reported as below:
|
| Oxygen and Oxygen Equipment Payment Categories | Oxygen and oxygen equipment - Includes 36-month limit on monthly payments for stationary and portable oxygen equipment. Replacement of oxygen, change in oxygen equipment during reasonable useful lifetime period, billing contents, and modifiers. |
Reviews/Audits
- Medical Review - View notifications/findings of pre/post claim reviews completed by Noridian Medical Review
Resources
Last Updated Dec 09 , 2023
