Oxygen Insurance Guidelines
REQUIRED DOCUMENTATION IN SUPPLIER’S FILE
All Claims for Oxygen: Initial Certification
+ 5 Element Order obtained prior to Delivery for the HCPCS code E1390, E0431, E0443:
- 5 Element order contains:
– Beneficiary’s name
– Practitioner’s NPI
– General description of the item
– Practioner’s signature
– Order date - The date of the order is on or after a face-to-face encounter between the ordering physician and the beneficiary.
- The 5EO was obtained prior to delivery.
- A date stamp (or similar) clearly indicates the supplier’s date of receipt.
- Any changes or corrections have been initialed/signed and dated by the ordering physician.
+ Documentation of Dispensing Order (preliminary written or verbal order) that contains:
- Description of the item
- Name of the beneficiary
- Name of the physician
- Date of the order
- Physician signature (for written order) or supplier signature (for verbal order)
NOTE: If the claim includes HCPCS codeE1390, E0431, E0443, a 5 Element Order must be obtained prior to delivery. This home oxygen equipment cannot be delivered based on a dispensing order. A dispensing order for other equipment related to home oxygen therapy is only required if the items are dispensed prior to obtaining the detailed written order.
+ Detailed Written Order That Contains:
- Beneficiary’s name
- The treating physician’s name
- The treating physician’s signature
- The date the treating physician signed the order (personally entered by the physician)
- The date of the order
- The item(s) to be dispensed – Must include all separately billed accessories/supplies and specify quantity to provide and replacement frequency The means of oxygen delivery (cannula, mask, etc.)
- The flow rate and frequency of use
+ Physician’s signature on the written order meets CMS Signature Requirements
+ Certificate of Medical Necessity for Home Oxygen (The CMN may act as a substitute for a written order if it is sufficiently detailed)
+ Proof of Delivery
- Beneficiary’s name
- Quantity delivered
- Detailed description of item(s)
- Manufacturer
- Serial number
- Delivery date
- Signature of person accepting delivery
- Relationship to beneficiary
+ Medical records supporting that the patient meets the basic coverage criteria specified in the coverage and payment rules section of the Oxygen and Oxygen Equipment LCD
– 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 has had a blood gas study that meets one of the following criteria, AND:
- At rest (awake but sitting or lying down), the arterial PO2 is at or below 55 mm Hg or the arterial oxygen saturation is at or below 88%.
- While awake, the patient’s arterial P02 is > 56 mm Hg or the arterial oxygen saturation is > 89% but, for at least 5 minutes during sleep, the arterial PO2 falls to < 55 mg Hg or the arterial oxygen saturation to < 88%.
- During sleep, there is a decrease in the arterial PO2 of more than 10mm Hg or a decrease in the arterial oxygen saturation of more than 5% from baseline saturation for at least 5 minutes and the decrease in PO2 or O2 saturation is associated with symptoms or signs reasonably attributable to hypoxemia.
- At rest, the patient’s arterial PO2 is > 56 mm Hg or the arterial oxygen saturation is > 89% on room air but, during exercise, the arterial PO2 falls to < 55 mm Hg or the arterial oxygen saturation is < 88% and, oxygen administration improves the hypoxemia and, medical record includes all of the following: —
- Blood gas study performed at rest without oxygen;
- Blood gas study performed during exercise without oxygen; and
- Blood gas study performed during exercise with oxygen applied that demonstrates improvement of the hypoxemia
NOTE: All three qualifying blood gas study reading should be taken during a single testing session. The blood gas reading obtained during exercise, while breathing room air, is the number that should be recorded on the CMN. However, all three readings must be recorded in the medical record and available to the DME MAC or other Medicare contractors upon request.
– The qualifying blood gas study was performed by a physician or by a qualified provider or supplier of laboratory services (blood gas studies performed by a supplier are not acceptable), AND
– The qualifying blood gas study was obtained under one of the following conditions:
- Performed during an inpatient hospital stay, no earlier than 2 days prior to the hospital discharge date, and was the last test obtained prior to discharge; or
- Was not performed during an inpatient hospital stay and was performed while the patient was in a chronic stable state, not during a period of acute illness or an exacerbation of their underlying disease, AND
– The qualifying blood gas study was the most recent study obtained prior to the Initial Date indicated in Section A of the CMN and this study was obtained within 30 days prior to the Initial Date, AND
– The patient was seen and evaluated by the treating physician within 30 days prior to the date of initial certification, AND
– Alternative treatment measures have been tried or considered and deemed clinically ineffective.
+ Physician’s signature on the written order meets CMS Signature Requirements
Recertification (Required 12 months after Initial Certification)
+ Recertification CMN
+ Medical records documenting that the patient was seen and re-evaluated by the treating physician within 90 days prior to the date of the recertification. ** If the physician visit is not obtained within the 90-day window but the beneficary continutes to use oxygen and the visit is obtained at a later date, coverage would resume beginning with the date of that visit. The date of the visit is the recertifcation date that must be entered on the Recertification CMN.
+ Continued medical need for the equipment/accessories/supplies is verified by either:
- A refill order from the treating physician dated within 12 months of the date of service under review; or
- A change in prescription dated within 12 months of the date of service under review; or
- A properly completed CMN with an appropriate length of need specified; or
- A medical record, dated within 12 months of the date of service under review that shows usage of the item.
Portable Oxygen Systems
+ Medical records that support:
- The patient is mobile within the home; and
- The qualifying blood gas study was performed at rest (awake) or during exercise
+ Liter flow greater than 4 LPM
- A copy of a blood gas study showing blood gas levels in the Group I or Group II range while the patient was receiving oxygen at the rate of 4 LPM
(This document was prepared as an educational tool and is not intended to grant rights or impose obligations. This checklist may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either written law or regulations. Suppliers are encouraged to consult the DME MAC Jurisdiction C Supplier Manual and the Local Coverage Determination/Policy Article for full and accurate details concerning policies and regulations.)