OAR 410-122-0203
Oxygen and Oxygen Equipment
(1)
Indications and limitations of coverage and medical appropriateness: the Division may cover home oxygen therapy services. Refer to Table 122-0203-1 and the following guidelines:(a)
For children under age 19 when the treating practitioner has determined oxygen services to be medically appropriate; or(b)
For adults age 19 years of age and older who are fully dual-eligible clients (Medicare clients who are also eligible for Medicaid/Oregon Health Plan (OHP); See definition in General Rules, OAR 410-120-0000 (Acronyms and Definitions)), the Division of Medical Assistance Programs (Division) may cover oxygen services as follows:(A)
If Medicare paid on the claim for the oxygen equipment, the Division may provide reimbursement;(B)
If Medicare denied payment on the claim for the oxygen equipment, the Division will not provide reimbursement in accordance with Medicare rules and regulations;(C)
Refer to the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Supplemental Information for additional details on Medicare’s reimbursement limitation of 36 monthly rental payments;(c)
For adults 19 years of age and older who are not eligible for Medicare (only eligible for Medicaid/OHP), PA is required effective January 1, 2010 and all of the following conditions must be met:(A)
The treating practitioner has determined that the client has a severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy;(B)
The client’s blood gas study meets the criteria stated below;(C)
The qualifying blood gas study was performed by a physician or by a qualified provider or supplier of laboratory services;(D)
The qualifying blood gas study was obtained under the following conditions:(i)
If the qualifying blood gas study is performed during an inpatient hospital stay, the reported test must be the one obtained closest to, but no earlier than two days prior to the hospital discharge date; or(ii)
If the qualifying blood gas study is not performed during an inpatient hospital stay, the reported test must be performed while the client is in a chronic stable state — i.e., not during a period of acute illness or an exacerbation of their underlying disease;(E)
Alternative treatment measures have been tried or considered and deemed clinically ineffective;(d)
Group I coverage duration and indications:(A)
Initial coverage for clients meeting Group I criteria is limited to 12 months or the practitioner-specified length of need, whichever is shorter. See information on recertification in section 3(g) and (6);(B)
Group I criteria include any of the following:(i)
An arterial partial pressure of oxygen (PO2) at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent taken at rest (awake);(ii)
An arterial PO2 at or below 55 mm Hg, or an arterial oxygen saturation at or below 88 percent, for at least 5 minutes taken during sleep for a client who demonstrates an arterial PO2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89 percent while awake;(iii)
A decrease in arterial PO2 more than 10 mm Hg, or a decrease in arterial oxygen saturation more than 5 percent, for at least five minutes taken during sleep associated with symptoms (e.g., impairment of cognitive processes and [nocturnal restlessness or insomnia]) or signs (e.g., cor pulmonale, “P” pulmonale on EKG, documented pulmonary hypertension and erythrocytosis) reasonably attributable to hypoxemia;(iv)
An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent, taken during exercise for a client who demonstrates an arterial PO2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89 percent during the day while at rest. In this case, oxygen is provided for during exercise if it is documented that the use of oxygen improves the hypoxemia that was demonstrated during exercise when the client was breathing room air;(e)
Group II coverage duration and indications:(A)
Initial coverage for clients meeting Group II criteria is limited to three months or the practitioner-specified length of need, whichever is shorter. See information on recertification in section 3(g) and (6);(B)
Group II criteria include the presence of an arterial PO2 of 56-59 mm Hg or an arterial blood oxygen saturation of 89 percent at rest (awake), during sleep for at least five minutes, or during exercise (as described under Group I criteria) and any of the following:(i)
Dependent edema suggesting congestive heart failure;(ii)
Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery pressure; gated blood pool scan, echocardiogram, or “P” pulmonale on EKG (P wave greater than 3 mm in standard leads II, III, or AVF);(iii)
Erythrocythemia with a hematocrit greater than 56 percent;(f)
Group III indications include a presumption of non-coverage. Criteria include arterial PO2 levels at or above 60 mm Hg or arterial blood oxygen saturations at or above 90 percent;(g)
For all the sleep oximetry criteria, the five minutes does not have to be continuous;(h)
When both arterial blood gas (ABG) and oximetry tests have been performed on the same day under the same conditions (i.e., at rest/awake, during exercise, or during sleep), the ABG result will be used to determine if the coverage criteria were met;(i)
If an ABG test at rest/awake is nonqualifying, but an exercise or sleep oximetry test on the same day is qualifying, the oximetry test result will determine coverage;(j)
Oxygen therapy and related services, equipment or supplies are not covered for any of the following:(A)
Angina pectoris in the absence of hypoxemia. This condition is generally not the result of a low oxygen level in the blood and there are other preferred treatments;(B)
Dyspnea without cor pulmonale or evidence of hypoxemia;(C)
Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities but in the absence of systemic hypoxemia. There is no evidence that increased PO2 will improve the oxygenation of tissues with impaired circulation;(D)
Terminal illnesses that do not affect the respiratory system;(E)
Group III clients;(F)
Emergency or stand-by oxygen systems for clients who are not regularly using oxygen since these services are precautionary and not therapeutic in nature;(G)
Topical hyperbaric oxygen chambers (A4575);(H)
When furnished by an airline (responsibility of the client);(I)
When provided/used outside the United States and its territories.(2)
Testing Specifications:(a)
The term blood gas study in this policy refers to either an ABG test or an oximetry test:(A)
An ABG is the direct measurement of the PO2 on a sample of arterial blood. The PO2 is reported as mm Hg.(B)
An oximetry test is the indirect measurement of arterial oxygen saturation using a sensor on the ear or finger. The saturation is reported as a percent;(b)
The qualifying blood gas study must be one that complies with the Fiscal Intermediary, Local Carrier, or A/B Medicare Administrative Contractor (MAC) policy on the standards for conducting the test and is covered under Medicare Part A or Part B;(c)
The test must be performed by a qualified provider (a laboratory, a physician, etc.):(A)
A DMEPOS provider is not considered a qualified provider or a qualified laboratory for purposes of this policy;(B)
Division will not accept blood gas studies either performed or paid for by a DMEPOS provider;(C)
This prohibition does not extend to blood gas studies performed by a hospital certified to do such tests;(d)
When oxygen is covered based on an oxygen study obtained during exercise, documentation of three oxygen studies performed within the same testing session in the client’s medical record is required:(A)
Testing at rest without oxygen;(B)
Testing during exercise without oxygen; and(C)
Testing during exercise with oxygen applied, to demonstrate the improvement of the hypoxemia;(e)
Only the qualifying test value (i.e., testing during exercise without oxygen) is reported on the Certificate of Medical Necessity (CMN). The other results do not have to be routinely submitted but must be available on request;(f)
The qualifying blood gas study may be performed while the client is on oxygen as long as the reported blood gas values meet the Group I or Group II criteria.(3)
Certification:(a)
A completed and signed CMN is required to receive payment for oxygen;(b)
The blood gas study must be the most recent study obtained within 30 days prior to the initial date, indicated in Section A of the CMN;(c)
There is an exception to the 30-day test requirement for clients who were started on oxygen while enrolled in a Division health maintenance organization (HMO) and transition to fee-for-service. For those clients, the blood gas study does not have to be obtained 30 days prior to the Initial Date, but must be the most recent qualifying test obtained while in the HMO;(d)
The client must be seen and evaluated by the treating practitioner within 30 days prior to the date of Initial Certification;(e)
Initial CMN is required for any of the following situations:(A)
With the first claim to the Division for home oxygen, (even if the client was on oxygen prior to becoming eligible for Division coverage;(B)
When there has been a change in the client’s condition that has caused a break in medical necessity of at least 60 days plus whatever days remain in the rental month during which the need for oxygen ended;(C)
When an initial CMN does not meet coverage criteria and the client was subsequently retested and meets coverage criteria;(D)
When a Group I client with a length of need less than or equal to 12 months was not retested prior to a revised certification/recertification, but a qualifying study was subsequently performed;(E)
When the client initially qualified in Group II, repeat blood gas studies were not performed between the 61st and 90th day of coverage, but a qualifying study was subsequently performed;(F)
When there was a change of DMEPOS provider due to an acquisition and the previous provider did not file a recertification when it was due and the requirements for the recertification were not met when it was due;(G)
When the equipment is replaced in the following situations:(i)
The reasonable useful lifetime of prior equipment has been reached; or(ii)
Irreparable damage, theft or loss of the originally dispensed equipment:(I)
Irreparable damage refers to a specific accident or a natural disaster (e.g., fire, flood); and(II)
Irreparable damage does not refer to wear and tear over time;(f)
For initial CMN of replacement equipment described in (3)(e)(G):(A)
Repeat blood gas testing is not required. Enter the most recent qualifying value and test date. This test does not have to be within 30 days prior to the Initial Date. It could be the test result reported on the most recent prior CMN;(B)
There is no requirement for a practitioner visit that is specifically related to the completion of the CMN for replacement equipment;(g)
Recertification CMN is required in the following situations:(A)
Group I — 12 months after initial certification (i.e., with the thirteenth month’s claim);(B)
Group II — 3 months after initial certification (i.e., with the fourth month’s claim);(C)
Recertification following initial certification done in section (3)(e)(A & B):(i)
For clients initially meeting Group I criteria, the most recent qualifying blood gas study prior to the thirteenth month of therapy must be reported on the recertification CMN;(ii)
For clients initially meeting Group II criteria, the most recent blood gas study that was performed between the 61st and 90th day following initial certification must be reported on the recertification CMN. If a qualifying test is not obtained between the 61st and 90th day of home oxygen therapy but the client continues to use oxygen and a test is obtained at a later date, if that test meets Group I or II criteria, coverage would resume beginning with the date of that test;(iii)
For clients initially meeting Group I or II criteria, the client must be seen and re-evaluated by the treating practitioner 90 days prior to the date of any recertification. If the practitioner visit is not obtained within the 90-day window but the client continues to use oxygen and the visit is obtained at a later date, coverage would resume beginning with the date of that visit;(h)
Recertification following replacement equipment described in (3)(e)(G):(A)
Repeat testing is not required. Enter the most recent qualifying value and test date. This test does not have to be within 30 days prior to the Initial Date. It could be the test result reported on the most recent prior CMN;(B)
There is no requirement for a practitioner visit that is specifically related to the completion of the CMN for replacement equipment;(i)
The DMEPOS provider must submit a revised CMN in the following circumstances. The Division does not require a practitioner visit in these situations. Submission of a revised CMN does not change the recertification schedule specified elsewhere:(A)
When the prescribed maximum flow rate changes from one of the following categories to another. In this situation, the blood gas study must be the most recent study obtained within 30 days prior to the initial date:(i)
Less than 1 liter per minute (LPM);(ii)
1-4 LPM;(iii)
Greater than 4 LPM;(B)
If the change is from less than 1 LPM or 1-4 LPM to greater than 4 LPM, a repeat blood gas study with the client on 4 LPM must be performed within 30 days prior to the start of the greater than 4 LPM flow. In this situation, the blood gas study must be the most recent study obtained within 30 days prior to the initial date;(C)
When the length of need expires — if the practitioner-specified less than lifetime length of need on the most recent CMN. In this situation, the blood gas study must be the most recent study obtained within 30 days prior to the initial date;(D)
When a portable oxygen system is added subsequent to initial certification of a stationary system. In this situation, the Division does not require a repeat blood gas study unless the initial qualifying study was performed during sleep, in which case a repeat study must be performed while the client is awake or during exercise (within 30 days of revised date);(E)
When a stationary system is added subsequent to initial certification of a portable system. In this situation, the Divisiondoes not require a repeat blood gas study. A revised CMN does not need to be submitted with claims but must be kept on file by DMEPOS provider;(F)
When there is a new treating practitioner but the oxygen order is the same. In this situation, the Division does not require a repeat blood gas study. The revised certification does not have to be submitted with the claim;(G)
If there is a new DMEPOS provider and that provider does not have the prior CMN. In this situation, the Division does not a repeat blood gas study. The revised certification does not have to be submitted with the claim;(H)
If the indications for a revised CMN are met at the same time that a recertification CMN is due, file the CMN as a recertification CMN.(4)
Portable Oxygen Systems:(a)
A portable oxygen system may be covered if the client is mobile within the home and the qualifying blood gas study was performed while at rest (awake) or during exercise. If the only qualifying blood gas study was performed during sleep, portable oxygen is not covered;(b)
If coverage criteria are met, a portable oxygen system is usually separately payable in addition to the stationary system. See exception in (5) below;(c)
If a portable oxygen system is covered, the DMEPOS provider must provide whatever quantity of oxygen the client uses; the reimbursement is the same, regardless of the quantity of oxygen dispensed.(5)
Liter flow greater than 4 LPM:(a)
The Division will pay a higher allowance for a stationary system for a flow rate of greater than 4 LPM only when:(A)
Basic oxygen coverage criteria have been met; and(B)
A blood gas study performed while the client is on 4 LPM meets Group I or II criteria;(b)
Payment is limited to the standard fee schedule allowance if a flow rate greater than 4 LPM is billed and the coverage criteria for the higher allowance are not met;(c)
If a client qualifies for additional payment for greater than 4 LPM of oxygen and also meets the requirements for portable oxygen:(A)
The Division will pay for either the stationary system (at the higher allowance) or the portable system (at the standard fee schedule allowance for a portable system), but not both;(B)
In this situation, if both a stationary system and a portable system are requested for the same rental month, the Division will not cover the portable oxygen system.(6)
Documentation Requirements: The DMEPOS provider must submit documentation which supports conditions of coverage as specified in this rule are met:(a)
A CMN which has been completed, signed, and dated by the treating practitioner:(A)
The CMN may act as a substitute for a written order if it is sufficiently detailed;(B)
The CMN for home oxygen is CMS Form 484 (DME form 484.03). Section B (order information), must be completed by the physician or the practitioner, not the DMEPOS provider. The DMEPOS provider may use Section C for a written confirmation of other details of the oxygen order, or the practitioner can enter the other details directly, such as the means of oxygen delivery (cannula, mask, etc.) and the specifics of varying oxygen flow rates and/or non-continuous use of oxygen;(C)
The ABG PO2 must be reported on the CMN if both an arterial blood gas and oximetry test were performed on the same day under the condition reported on the CMN (i.e., at rest/awake, during exercise, or during sleep);(D)
A report of the sleep study documenting the qualifying desaturation for clients who qualify for oxygen based only on a sleep oximetry study. The oxygen saturation value reported in question 1b of the Oxygen CMN must be the lowest value (not related to artifact) during the five minute qualifying period reported on the sleep oximetry study;(b)
The treating practitioner’s signed and dated order for each item billed. Items billed before a signed and dated order has been received by the DMEPOS provider must be submitted with an EY modifier added to each affected Healthcare Common Procedure Coding System (HCPCS) code;(c)
The following special instructions apply to replacement equipment for those situations described in (3)(e)(G):(A)
Initial date should be the date that the replacement equipment is initially needed. This is generally understood to be the date of delivery of the oxygen equipment;(B)
The recertification date should be 12 months following the initial date when the value on the initial CMN (for the replacement equipment) meets Group I criteria or 3 months following the initial date when the qualifying blood gas value on the initial CMN meets the Group II criteria (Note: The initial date should also be entered on the recertification CMN.);(C)
Claims for the initial rental month (and only the initial rental month) must have the RA modifier (Replacement of DME item) added to the HCPCS code for the equipment when there is replacement due to reasonable useful lifetime or replacement due to damage, theft, or loss;(D)
Claims for the initial rental month must include a narrative explanation of the reason why the equipment was replaced and supporting documentation must be maintained in the DMEPOS provider’s files;(d)
In the following situations, a new order must be obtained and kept on file by the DMEPOS provider, but neither a new CMN nor a repeat blood gas study are required:(A)
Prescribed maximum flow rate changes but remains within one of the following:(i)
Less than 1 LPM;(ii)
1-4 LPM;(iii)
Greater than 4 LPM;(B)
Change from one type of stationary system to another (i.e., concentrator, liquid, gaseous);(C)
Change from one type of portable system to another (i.e., gaseous or liquid tanks, portable concentrator, transfilling system).(7)
Oxygen contents:(a)
The Division allowance for rented oxygen systems includes oxygen contents;(b)
Stationary oxygen contents (E0441, E0442) are separately payable only when the coverage criteria for home oxygen have been met and they are used with a client-owned stationary gaseous or liquid system respectively;(c)
Portable contents (E0443, E0444) are separately payable only when the coverage criteria for home oxygen have been met and:(A)
The client owns a concentrator and rents or owns a portable system; or(B)
The client rents or owns a portable system and has no stationary system (concentrator, gaseous, or liquid);(C)
If the criteria for separate payment of contents are met, they are separately payable regardless of the date that the stationary or portable system was purchased;(d)
Refer to Table 122-0203-2 for oxygen contents that may be reimbursable for dual-eligible clients.(8)
Oxygen accessory items:(a)
The allowance for rented systems includes, but is not limited to, the following accessories:(A)
Transtracheal catheters (A4608);(B)
Cannulas (A4615);(C)
Tubing (A4616);(D)
Mouthpieces (A4617);(E)
Face tent (A4619);(F)
Masks (A4620, A7525);(G)
Oxygen tent (E0455);(H)
Humidifiers (E0550, E0555, E0560);(I)
Nebulizer for humidification (E0580);(J)
Regulators (E1353);(K)
Stand/rack (E1355);(b)
The DMEPOS provider must provide any accessory ordered by the practitioner;(c)
Accessories are separately payable only when they are used with a client-owned system that was purchased prior to June 1, 1989. The Division does not cover accessories used with a client-owned system that was purchased on or after June 1, 1989.(9)
Billing for miscellaneous oxygen items:(a)
Only rented oxygen systems (E0424, E0431, E0434, E0439, E1390RR, E1405 RR, E1406RR, E1392RR) are considered for coverage;(b)
For gaseous or liquid oxygen systems or contents, report one unit of service for one month rental. Do not report in cubic feet or pounds;(c)
Use the appropriate modifier if the prescribed flow rate is less than 1 LPM (QE) or greater than 4 LPM (QF or QG). Division only accepts these modifiers with stationary gaseous (E0424) or liquid (E0439) systems or with an oxygen concentrator (E1390, E1391). Do not use these modifiers with codes for portable systems or oxygen contents;(d)
Use Code E1391 (oxygen concentrator, dual delivery port) in situations in which two clients are both using the same concentrator. In this situation, this code must only be requested for one of the clients;(e)
For E1405 and E1406 (oxygen and water vapor enriching systems), products must be coded as published by the Pricing, Data Analysis and Coding (PDAC) Contractor by the Centers for Medicare and Medicaid Services;(f) Code E1392 describes a portable oxygen concentrator system. Use E1392 when billing the Division for the portable equipment add-on fee for clients using lightweight oxygen concentrators that can function as both the client’s stationary equipment and portable equipment. A portable concentrator:(A)
Weighs less than 10 pounds;(B)
Is capable of delivering 85 percent or greater oxygen concentration; and(C)
Is capable of providing at least two hours of remote portability at a 2 LPM order equivalency;(g)
Contact the PDAC for guidance on the correct coding of these items.(10)
Table 122-0203-1, Oxygen and Oxygen Equipment.(11)
Table 122-0203-2, Oxygen Contents.
Source:
Rule 410-122-0203 — Oxygen and Oxygen Equipment, https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-122-0203.