Oxygen

Coverage

Documentation

Oxygen Q Modifiers

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
  • SAT cannot be 90 or above
  • ABG cannot be 60 or above
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
  • SAT cannot be 90 or above
  • ABG cannot be 60 or above
Stationary:
Fee Schedule

Portable:
.5 of the fee for the stationary or the portable amount whichever is greater

 

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.

Reviews/Audits

  • Medical Review - View notifications/findings of pre/post claim reviews completed by Noridian Medical Review

Numerical 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:

  • If value is 12.01 to 12.49, round down to 12
  • If value is 12.50 to 12.99, round up to 13

The only exceptions to this rule are where Medicare policy makes clear that the specified level is absolute and rounding is not to be used. One such situation is in the completion of Question 5 on the Oxygen Certificate of Medical Necessity ("Enter the highest oxygen flow rate ordered for this patient in liters per minute. If less than 1 LPM, enter a 'X'."). No rounding is allowed for flow rates less than 1.0.

Resources

 

Last Updated Sep 06, 2018

The below are topic specific articles which have been published to "Latest Updates" and sent out in Noridian emails within the past two years. Exclusions to this include time sensitive related announcements such as: Noridian and CMS educational events, Ask-the-Contractor Teleconferences and claims processing downtime.