Home Oxygen Therapy

January 22nd, 2019 - Raquel Shumway

Medicare will cover certain oxygen items/equipment for Home use, provided there is proper documentation showing that they are both reasonable and necessary in accordance with local MAC policies (LCDs). Here are a few of the highlights regarding those items and the requirements as found in Medicare's MLN Home Oxygen Therapy Booklet which also includes additional information.

Oxygen DME -- Covered and Noncovered

In order for these items to be covered, Medicare requires that they are:

Eligible for a defined Medicare benefit category
Reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member
Ordered by providers and furnished by suppliers who are enrolled in the Medicare Program and
Meet all other applicable Medicare statutory and regulatory requirements

To be considered reasonable and necessary these items must meet ALL of the required criteria.

Reasonable and Necessary Criteria

Initial Certifications Tables 1-3

Patient’s blood gas study values must meet one of these criteria: (either an arterial blood gas or an oximetry test)

Table 1: Group 1 Criteria

Initial Certification for Blood Gas Study - Group 1 Criteria

Table 2: Group 2 Criteria

Medicare will deny claim as not reasonable and not necessary if the only qualifying blood gas study is performed during sleep.

Initial Certification for Blood Gas Study - Group 2 Criteria

Table 3: Group 3 Criteria:

May be covered when patients are enrolled in a CMS approved clinical trial.

Initial Certification for Blood Gas Study - Group 3

Home Oxygen Therapy also includes specific requirements for providers, and suppliers of DME on the following topics (Click on each link below for further information):

A Face-to-Fact Encounter: Required by the new Affordable Care Act.
The Medical Record: Must contain sufficient documentation to substantiate the need for home oxygen therapy
A Written Order (Prescription) Prior to Delivery (WOPD): An order written that must be provided to the supplier BEFORE the delivery of the oxygen and/or equipment to the patient.
The Certificate of Medical Necessity (CMN) for Oxygen
Advance Beneficiary Notice of Noncoverage (ABN) (page 29)
Payment for Oxygen Items and Equipment (page 29-30)

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