Oxygen Guidelines

1
Oxygen Guidelines

• O2 is prescribed for patients with hypoxemia in
  the chronic state
• If a patient is diagnosed with a severe lung
  disease such as
• COPD, interstitial lung disease, cystic fibrosis,
  bronchiectasis, pulmonary neoplasm,
• If a patient is diagnosed with hypoxia-related
  symptoms that may improve with oxygen
• pulmonary hypertension, congestive heart failure,
  cor pulmonale, erthrocytosis.
• To qualify for Oxygen, the following conditions
  must be met
• Doctor has determined that the patient has a
  severe lung disease that may improve with oxygen.
• Patients blood gas levels indicate the need for
  oxygen.
• Alternative measures have been tried or
  considered and deemed clinically ineffective.
• A physicians CMN, (Certificate of Medical
  Necessity), is required to be completed
  accurately.

2
CMN

• A Physicians CMN must specify
• Diagnosis of the disease requiring oxygen
  therapy.
• The oxygen flow rate.
• The frequency of oxygen use.
• The length of need.

3
Three Basic Oxygen Groups

• Group I
• Oxygen is covered if the arterial blood gas (PO2)
  is less than or equal to 55 mm Hg or the O2
  saturation as measured by a pulse oximeter less
  than or equal to 88 (awake and at rest).
• If a patient has higher levels, but demonstrates
  desaturation to these levels during sleep or
  exercise, then oxygen may be reimbursed, with
  additional testing. If during sleep, the levels
  are higher than 55 or O2 sat higher than 88, but
  represent a drop of 10mm Hg (ABG) or 5 (O2 Sat)
  from awake , at rest levels, and associated with
  demonstrated cor pulmonale, pulmonary
  hypertension, and erthrocytosis, the patient may
  qualify.
• Group II
• If the ABG is 56-59 or the O2 sat is at 89 -
  covered if
• Dependent endema secondary to congestive heart
  failure, cor pulmonale, erythrocytosis
• Group III
• If ABG is 60 or greater or the O2 sat is 90 or
  greater, Medicare will not cover oxygen because
  oxygen is not considered medically necessary.

4
Physician Evaluation and Recertification

• Initial Certification Group I and II patients
  need to be evaluated within 30 days prior to the
  date of initial certification.
• Recertification Group I patients with a
  prescribed length of need of less than lifetime
  are required to be re-tested within 30 days
  prior to recertification. Group II patients
  must be tested between the 61st and 90th day
  after the date of initial certification.
• Patients ABG (PO2) or O2 saturation must be
  performed with the patient in a chronic stable
  state as an outpatient OR within 2 days prior to
  discharge.
• If oxygen coverage is approved, the coverage
  applies regardless of the oxygen modality
  selected. If coverage is approved, any equipment
  and supplies necessary to the patients use of
  covered home oxygen therapy, like regulators,
  humidifiers and face masks are also covered.
  Back-up oxygen tanks are not covered. Supplies
  are not separately reimbursed unless the
  equipment is owned by the patient.
• Portable Oxygen is billed separately if the
  patient is mobile.