Oxygen Modifier Decision Tree

Is the prescribed oxygen portable or stationary?

   

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

   

Modifier RR (Rental), and Modifier KX (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 RR (Rental), Modifier QF, and Modifier KX (Coverage criteria met) or Liability Modifier (GA, GY, GZ)

Modifier RR (Rental), Modifier QB, and Modifier KX (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 RR (Rental), Modifier QE, and Modifier KX (Coverage criteria met) or Liability Modifier (GA, GY, GZ)

Modifier RR (Rental), and Modifier KX (Coverage criteria met) or Liability Modifier (GA, GY, GZ)

If Portable Oxygen is Prescribed:

  • Modifier RR (Rental), Modifier QF, and Modifier KX (Coverage criteria met) or Liability Modifier (GA, GY, GZ)

 

If No Portable Oxygen is Prescribed:

  • Modifier RR (Rental), Modifier QG, and Modifier KX (Coverage criteria met) or Liability Modifier (GA, GY, GZ)

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

      

Modifier RR (Rental), Modifier QA, and Modifier KX (Coverage criteria met) or Liability Modifier (GA, GY, GZ)

Modifier RR (Rental), and Modifier KX (Coverage criteria met) or Liability Modifier (GA, GY, GZ)

If Portable Oxygen is Prescribed:

  • Modifier RR (Rental), Modifier QB, and Modifier KX (Coverage criteria met) or Liability Modifier (GA, GY, GZ)

 

If No Portable Oxygen is Prescribed:

  • Modifier RR (Rental), Modifier QR, and Modifier KX (Coverage criteria met) or Liability Modifier (GA, GY, GZ)
 

Last Updated Nov 30, 2018