RETIRED - Billing Instruction - Oxygen CMN Question 5 - Revised - JA DME

Joint DME MAC Article

On February 15, 2018 the DME MACs published an article entitled "Billing Instruction - Oxygen CMN Question 5" with supplier guidance on use of new oxygen "Q" modifiers and the Certificate of Medical Necessity (CMN) (CMS-484/DME 484.3) form.  The article provided instructions for providers to report the calculated average flow rate for Question 5 on the CMN form when there are differing daytime and nighttime prescribed flow rates.  In addition, the article instructed suppliers to submit revised CMNs in this situation for dates of service (DOS) on or after April 1, 2018.  The instruction to submit revised CMNs is being rescinded.  Suppliers should educate providers completing the oxygen CMN to follow the instructions included on page 2 of the CMN.  As a reminder, the instructions on the Oxygen CMN for Question 5 state:

5. Enter the highest oxygen flow rate ordered for this patient in liters per minute.  If less than 1 LPM, enter an "X".

For DOS on or after April 1, 2018, suppliers must still use the appropriate "Q" modifier on claim lines for oxygen equipment.  Those modifiers are:

• QE - PRESCRIBED AMOUNT OF STATIONARY OXYGEN WHILE AT REST IS LESS THAN 1 LITER PER MINUTE (LPM)
• QF - PRESCRIBED AMOUNT OF STATIONARY OXYGEN WHILE AT REST EXCEEDS 4 LITERS PER MINUTE (LPM) AND PORTABLE OXYGEN IS PRESCRIBED
• QG - PRESCRIBED AMOUNT OF STATIONARY OXYGEN WHILE AT REST IS GREATER THAN 4 LITERS PER MINUTE (LPM)
• 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)
• 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
• 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)

Suppliers must ensure that the appropriate "Q" modifier is used, based on information in the beneficiary's medical record.  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 beneficiary'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.

For beneficiaries with a single prescribed flow rate that doesn't encompass a full 24 hours, an average calculation is still required with the unaccounted for portion of the 24 hour period set equal to "0".  For example, if the only available prescribed flow rate is nocturnal at 2 LPM, a "0" is reported for the prescribed daytime flow rate.  Calculating the average of the night and day use yields an average reportable prescribed flow rate value of 1 LPM.  In order to properly calculate the average flow rate used to determine the appropriate "Q" modifier, the following example is provided:

(day flow rate + night flow rate) / 2 = average flow rate
(apply arithmetic rounding rules, if necessary)

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 beneficiary'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. 

Refer to the Oxygen and Oxygen Equipment Local Coverage Determination (L33797) and related Policy Articles for additional information on coverage, coding and documentation requirements.

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