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Document Type Description
CMS 484 – Oxygen [PDF] Oxygen Certificate of Medical Necessity (CMN)
Documentation Checklist [PDF] Suppliers may use this checklist to ensure all required documentation is gathered
Physician Letter – Continued Medical Need [PDF] This letter reminds physicians that ongoing need for and use of a DMEPOS item must be documented in patient's record
Physician Letter – Home Oxygen Initial Qualification Testing [PDF] This letter reviews blood oxygen testing requirements
Physician Letter – Oxygen and Oxygen Equipment [PDF] This letter may be sent to physicians to assist in obtaining appropriate documentation for oxygen and oxygen equipment



Reference Title Description
CMS Internet Only Manual (IOM) IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 20, Section 30.6, Oxygen and Oxygen Equipment
CMS FAQs Search CMS Frequently Asked Questions (FAQs) for answers on oxygen and oxygen equipment
Oxygen for Cluster Headache in Clinical Trial - CR7820 The HCPCS codes and modifiers used, effective October 1, 2012, to identify home use of oxygen for Cluster Headaches are provided



Review Type Description
Medical Review View notifications and findings of pre and post claim reviews completed by Noridian Medical Review Staff


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 the value is 12.01 to 12.49, round down to 12.
If the 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.


Last Updated Jan 09, 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.