Medicare Training 103

1
Medicare Training 103 Oxygen LCD Coverage
Payment Rules February 2010
2
Medicare Oxygen Coverage Payment Rules

• Training Topics
• Oxygen Coverage Criteria
• Testing Requirements
• Oxygen Coverage Groups I III
• Documentation Requirements
• Certification Requirements
• DRA New Payment Rules
• MIPPA Rules
• Oxygen Equipment Replacement
• DME MAC Resource Pages

3
Oxygen Basic Coverage Criteria

• Home oxygen therapy is covered only if all of the
  following conditions are met
• The treating physician has determined that the
  patient has a severe lung disease or
  hypoxia-related symptoms that might be expected
  to improve with oxygen therapy, and
• The patient's blood gas study meets the criteria
  stated below, and
• The qualifying blood gas study was performed by a
  physician or by a qualified provider or supplier
  of laboratory services, and (continued on next
  slide)

4
Oxygen Basic Coverage Criteria, Cont.

• There must be documentation in the patients
  medical record supporting that all of the basic
  coverage criteria is met
• Alternative treatment measures have been tried or
  considered and deemed clinically ineffective
• Initial physician assessment to determine the
  medical need for oxygen
• Qualifying test results
• Recertification physician assessment to determine
  continued medical need
• Documentation in the medical record that reflects
  the patient has on-going need for home oxygen
  therapy

5
Oxygen Basic Coverage Criteria Cont.

• The qualifying blood gas study was obtained under
  the following conditions
• 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 2 days prior to the hospital
  discharge date, or
• If the qualifying blood gas study is not
  performed during an inpatient hospital stay, the
  reported test must be performed while the patient
  is in a chronic stable state outpatient i.e.,
  not during a period of acute illness or an
  exacerbation of their underlying disease, and

6
Oxygen Blood Gas Definition

• In this policy, the term blood gas study includes
  both an
• Pulse Oximetry Test (oxygen saturation test)
• and
• Arterial Blood Gas (ABG) test

7
Oxygen Testing Specifications

• Medicare testing requirements
• Oxygen testing to qualify a patient for home
  oxygen therapy must be performed by a qualified
  practitioner or qualified provider of laboratory
  services
• Suppliers may not perform the test
  
• Suppliers may not pay for the test
• Suppliers may not use testing performed by
  another supplier
• The qualifying ABG/SAT test may be performed
• At rest (awake but sitting or lying down)
• During sleep
• During exercise (considered as either formal
  exercise or exertion while performing Activities
  of Daily Living (ADL)

8
Oxygen Testing Specifications

• The qualifying blood gas study must be performed
  by a provider who is qualified to bill Medicare
  for the test i.e., a Part A provider, a
  laboratory, an Independent Diagnostic Testing
  Facility (IDTF), or a physician.
• For sleep oximetry studies, the oximeter provided
  to the patient must be tamper-proof and must have
  the capability to download data that allows
  documentation of the duration of oxygen
  desaturation below a specified value
• The patient must desaturate a minimum of 5
  minutes below a specified value to qualify during
  sleep
• The physician must receive the results of the
  overnight oximetry from the IDTF the supplier
  may also receive the test results from the IDTF

9
Oxygen Testing Specifications

• Exercise Testing Criteria
• When oxygen is covered based on an oxygen study
  obtained during exercise, there must be
  documentation of three (3) oxygen tests/studies
  in the patients medical record i.e.,
• Testing at rest without oxygen,
• Testing during exercise without oxygen, and
• Testing during exercise with oxygen applied (to
  demonstrate the improvement of the hypoxemia).
• All 3 tests must be performed within the same
  testing session.
• Only the qualifying test value (e.g., testing
  during exercise without oxygen) is reported on
  the CMN.
• The other results do not have to be routinely
  submitted but must be available upon request.

10
Oxygen Coverage Groups

• Medicares oxygen coverage criteria divides
  beneficiaries into three oxygen coverage groups
• Group I
• Arterial PO2 is 55 mm Hg or less or Saturation is
  88 or less
• Group II
• Arterial PO2 is 56 59 mm Hg or Saturation is 89
• Group III
• Arterial PO2 is 60 mm Hg or greater or Saturation
  is 90 or greater
• Medicare payment is available for patients whose
  test results place them in Group I or Group II
  (if they meet additional criteria).
• Medicare does not cover oxygen for patients
  whose test results place them in Group III

11
Oxygen Required Documentation

• Medicare Required Documentation
• Verbal Order (if applicable)
• Written Order
• Certificate of Medical Necessity (CMN)
• Initial CMN
• Revised CMN (when applicable)
• Recertification CMN
• Proof of Delivery (POD)
• Delivery ticket that is signed and dated by the
  patient or designee that includes all of the
  required POD elements
• Recommended Documentation
• Copy of qualifying arterial blood gas (ABG) or
  pulse oximetry (SAT) test result report
• Medical records that support the beneficiary
  meets Medicare coverage criteria for oxygen
  therapy

12
Oxygen Initial CMN Requirements

• Group 1 and Group 11
• The blood gas study must be the most recent study
  obtained within 30 days prior to the Date of
  Initial Certification.
• Exception to the 30-day test requirement for
  patients who were started on oxygen while
  enrolled in a Medicare HMO and transition to
  fee-for-service Medicare.
• For those patients, the blood gas study does not
  have to be obtained within 30 days prior to the
  Initial Date, but must be the most recent
  qualifying test obtained while in the HMO.
• Medical Record must document the patient was seen
  and evaluated by the treating physician within 30
  days prior to the Date of Initial Certification.
• The patient must be seen and tested within 30
  days prior to the Initial Date on the Initial CMN
  (Exception patients moving from HMO to FFS)

13
Oxygen Recertification CMN Requirements

• Recertification for Group I
• Required 12 months after initial certification
• The blood gas reported should be the most recent
  blood gas study prior to the 13th month of
  therapy
• Recertification for Group II
• Required 3 months after initial certification
• The blood gas reported should be the most recent
  blood gas study performed between the 61st and
  90th day following initial certification
• Medical records must document the patient was
  seen and re-evaluated by the treating physician
  within 90 days prior to the date of
  recertification

14
Oxygen Recertification CMN Requirements

• Oxygen Therapy Revised CMN
• When the beneficiary changes suppliers and the
  new supplier cannot obtain the previous
  suppliers CMN and/or copies of the qualifying
  test results entered on the previous suppliers
  CMN the new supplier must obtain a Revised CMN
  and new qualifying test results
• When there is a new treating physician but the
  oxygen order is the same
• If there is a change in the length of need
• When there is a change in liter flow (if in a new
  liter flow group)
• When a portable system is added to a stationary
  system or a stationary system is added to a
  portable system
• Reminder
• Submission of a Revised CMN does not take the
  place of a required Recert CMN or change the CMN
  certification schedule

15
New Oxygen Payment Rules

• Deficit Reduction ACT (DRA) of 2005
• Oxygen equipment provided on or after 01/01/06
  will cap after 36 months of rental payments
• Equipment included in DRA 36 month oxygen cap
• Stationary gas system (E0424)
• Portable liquid system (E0434)
• Portable gaseous system (E0431)
• Stationary liquid system (E0439)
• Oxygen concentrator, single delivery (E1390) dual
  (E1391)
• Portable concentrator (E1392)
• Oxygen/water vapor system, heated (E1405)
  non-heated (E1406)

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New Oxygen Payment Rules

• Medicare Improvements for Patients and Providers
  Act (MIPPA) of 2008
• Supplier retains ownership of equipment
• Oxygen rental payment covers
• Equipment
• Contents
• Maintenance
• Supplies and accessories
• After 36 month period, Medicare will cover liquid
  or gaseous contents if a portable was billed
  during the rental period
• Reasonable and necessary maintenance or servicing
  of equipment may be covered beginning 6 months
  after the 36 month cap is met
• MIPPA defines Oxygen/DME useful lifetime to be 5
  years (60 months)

17
New Oxygen Payment RulesCont.

• Liquid or gaseous contents should be billed using
  codes E0441- E0444
• Medicare can pay a general maintenance and
  servicing (MS)visit for concentrators or
  trans-filling equipment beginning 6 months after
  the 36 month equipment cap
• MS modifier should be used with appropriate HCPCS
  code
• Accessories are not separately payable after the
  36 month cap
• No additional payment for supplier pickup or
  disposal of oxygen tanks

18
Oxygen Equipment Replacement

• New Capped Rental period (36 months) may begin
  when equipment is
• Lost
• Stolen
• Irreparably Damaged
• After continuous use for the equipments
  reasonable useful lifetime ( RUL)
• CMS defines DME reasonable useful lifetime to be
  5 years
• 60 Month Oxygen Replacement Process
• Break in Medical Need (Count 90 days from last
  bill date)
• New 36 month rental period begins on the date of
  the replacement oxygen equipment

19
Oxygen Equipment Replacement

• Explanation of the reason for replacement
  equipment
• Patient must choose a supplier for new 5 year
  service period
• Lost Patient Written Narrative
• Stolen Police Report
• Irreparably Damaged Specific Incident of Damage
• A New Initial CMN for replacement is required
• New testing is not required (if valid testing on
  file)
• New physician visit is not required
• The RA Modifier and related NTE Note must be
  submitted on the initial claim for the
  replacement oxygen equipment
• Replacement Recertification CMN follows the same
  schedule as standard oxygen recertification
  periods.
• New testing is not required (if valid testing on
  file)
• New physician visit is not required

20
Oxygen Reminders

• A Revised CMN never takes the place of a required
  Recert CMN unless a Recert CMN is due at the same
  time a Revised is needed in this case you obtain
  a Recertification CMN with the revised
  information.
• Patients moving from primary private insurance or
  primary Medicaid to Medicare must qualify under
  the current Medicare oxygen policy (LCD)
  guidelines.
• A new Initial CMN is required for Medicare
• Qualifying tests must be obtained within 30 days
  prior to the initial date on the Medicare CMN
• Physician evaluation must be performed within 30
  days prior to the initial date on the Medicare
  CMN
• Recertification requirements must be met for
  continued coverage

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Medicare DME MAC Resources

• Jurisdiction A
• Connecticut, Delaware, District of Columbia,
  Maine, Maryland, Massachusetts, New Hampshire,
  New Jersey, New York, Pennsylvania, Rhode Island
• Vermont National Heritage Insurance Company
• P.O. Box 9146
• Hingham, MA 02043-9146
• Phone/IVR 866.419.9458
• Customer Service 866.590.6731
• Website www.medicarenhic.com

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Medicare DME MAC Resources

• Jurisdiction B
• Illinois, Indiana, Kentucky, Michigan,
  Minnesota, Ohio, Wisconsin
• National Government Services
• PO Box 6036
• Indianapolis, IN 46206-6036
• Phone/IVR 877.299.7900
• Customer Service 866.590.6727
• Website www.ngsmedicare.com

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Medicare DME MAC Resources

• Jurisdiction C
• Alabama, Arkansas, Colorado, Florida, Georgia,
  Louisiana, Mississippi, New Mexico, North
  Carolina, Oklahoma, Puerto Rico, South Carolina,
  Tennessee, Texas, U.S. Virgin Islands, Virginia,
  West Virginia
• CIGNA Government Services
• PO Box 20010
• Nashville, TN 37202-0010
• Phone [phone]
  
• IVR 866-238-9650
• Telephone Re-Openings 866-813-7878
• Website www.cignagovernmentservices.com

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Medicare DME MAC Resources

• Jurisdiction D
• Alaska, American Samoa, Arizona, California,
  Guam, Hawaii, Idaho, Iowa, Kansas, Mariana
  Islands, Missouri, Montana, Nebraska, Nevada,
  North Dakota, Oregon, South Dakota, Utah,
  Washington, Wyoming
• Noridian Administrative Services
• 901 40th Ave. S., Suite 1
• Fargo, ND 58103-2146
• Phone [phone]
• IVR 877.320.0390
• Website www.noridianmedicare.com

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Medicare Oxygen Coverage Disclaimer

• This Medicare 103 Training module was created to
  provide you with a general overview of the
  Medicare Oxygen program.
• Official Medicare Program legal guidance is
  contained in the relevant statutes, regulations,
  rulings and CMS LCDs. TLC..

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Medicare Oxygen Coverage Disclaimer

• This presentation was current at the time it was
  published or uploaded onto the Web. Medicare
  policy changes frequently so links to the source
  documents have been provided within the document
  for your reference.
•  
• This presentation was prepared as a tool to
  assist providers and is not intended to grant
  rights, ensure coverage or impose obligations.
  Although every reasonable effort has been made to
  assure the accuracy of the information within
  these pages, the ultimate responsibility for the
  correct submission of claims and response to any
  remittance advice lies with the provider of
  service.
•  
• The Kentucky Medical Equipment Suppliers
  Association (KMESA) employees agents, and its
  staff make no representation, warranty, or
  guarantee that this compilation of Medicare
  information is error free and will bear no
  responsibility or liability for the results or
  consequences of the use of this guide. This
  publication is a general summary that explains
  certain aspects of the Medicare Program, but is
  not a legal document. The official Medicare
  Program provisions are contained in the relevant
  laws, regulations, and rulings.