Oxygen - JA DME
Oxygen
The Standard Written Order (SWO) requirements are in effect for dates of service January 1, 2020 and after.
Refer to the SWO page for the elements needed in this streamlined order.
Coverage
- Home Use of Oxygen (240.2) National Coverage Determination (NCD)
- Oxygen and Oxygen Equipment Local Coverage Determination (LCD) and Policy Article [PDF]
Documentation
- 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
- Clinician Letter - Oxygen and Oxygen Equipment [PDF] - Letter may be sent to clinicians to help obtain documentation
- CMS 484 - Oxygen Certificate of Medical Necessity (CMN) - Initial date is specific start date of medical necessity, or if a specific start date is not given, date of order is used
- 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 CMN: Question 6 Answered
|
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 CMN: Question 6 Answered
|
Stationary: Fee Schedule Portable: .5 of the fee for the stationary or the portable amount whichever is greater |
Tips
| Topic | Detail |
|---|---|
| Modifiers | Effective for claims with Dates of Service (DOS) on/after 08/01/18, use mandatory modifiers: KX, GA, GY, or GZ. Claim lines billed without one of these modifiers will be rejected as missing information. |
| 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:
|
Reviews/Audits
- Medical Review - View notifications/findings of pre/post claim reviews completed by Noridian Medical Review
Resources
- CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 20, Section 30.6, Oxygen and Oxygen Equipment
- CMS Medicare Learning Network (MLN) Matters (MM)7820 - Oxygen for Cluster Headache in Clinical Trial - The HCPCS codes and modifiers used, effective October 1, 2012, to identify home use of oxygen for Cluster Headaches are provided
Last Updated Wed, 27 Jan 2021 20:25:53 +0000
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