The key is to make sure there is documentation in the medical record indicating need for home oxygen therapy.

GROUP 1

1. Patient has a severe lung disease or hypoxia-related symptom that might improve therapy.

Examples:

• COPD, diffuse interstitial lung disease, bronchiectasis, cystic fibrosis
• Hypoxia related symptoms such as pulmonary hypertension, recurring CHF due to chronic cor pulmonale, erythrocytosis, impairment of congnitive process, nocturnal restlessness and morning headache.
• Hypoxemia alone will not be covered. There need to be an underlying condition causing the hypoxemia.
• Non-covered conditions: angina pectoris in absence of hypoxemia, breathlessness without cor pulmonate or hypoxemia, severe peripheral vascular disease, terminal illnesses that do not effect lungs, pneumonia.

2. Blood gas study meets criteria indicated below:

• Method1 : On room air at rest while awake, oxygen saturation equal to or less than 88percent or ABG equal to or less than= 55mm Hg
• Method2 : If during exercise must have the following three tests documented:
• 1. Oxygen saturation on room air at rest- (should be above 88 percent)
• 2. Oxygen saturation on room air with exercise - needs to be equal to or less than 88 percent
• 3. Oxygen saturation on oxygen with exercise - shows improvement with oxygen
• NOTE: If patient qualifies with method2, then WHOMEVER does the testing must document and provide all three test results of the above test results; otherwise the oxygen will not be covered.
• Method3 : During sleep in room air equal to or less than 88 percent for at least 5minutes and does not have to be continuous.

3.Alternative treatment measures, such as inhalers or nebulizer treatments, have been tried or considered, and ruled out or clinically ineffective.

For Group I, all three items listed above need to be met AND evidence of an in-person visit with treating practitioner that was done during office visit or as inpatient in a hospital setting must exist. The visit must have occurred within 30days prior to initial setup.

GROUP 2

1. Dependent edema suggesting CHF, OR

2. Pulmonary HTN or car pulmonale determined by measurement of pulmonary artery pressure, echocardiogram, or "P" pulmonale on EKG ,OR

3. Erthrocythemia with haematocrit greater than 56 percent , OR

4.ABG with PO2 of 56-59mm Hg or oxygen saturation of 89 percent at rest, while awake, during sleep for five minutes or during exercise as described under Group 1

Blood gas study :

1. Study must have been performed within 30days of initial setup, or during an impatient hospital stay and test done within two days prior to discharge date.

2. Performed while patient was in chronic stable state. Not during an acute illness or exacerbation of an underlying lung disease or in emergency room situation.

3. Blood gas study must have been performed by a physician or qualified provider or laboratory services that can bill Medicare such as an IDTE.

Helpful notes:

• If portable oxygen is being ordered, there needs to be documentation in the medical records indicating the patient is mobile within the home.
• Portable oxygen is considered when the blood gas study is performed while patient is awake or with exercise. At-night use only does not qualify for a portable unit.
• A frequent of use must be indicated , i.e. 2 Ipm or continuous or 3lpm at night, PRN, or as needed basis, is not covered by Medicare.
• DMEPOS suppliers are not considered as qualified to perform blood gas studies.
• If patient is under a part A covered stay payment such as hospital, nursing facility, home health or hospice meets the qualified provider standard. Need to be sure that patient is under a Part A covered payment ; if not , them the requirements are not met and qualification would be invalid.

Detailed Written order (DWO) must contain the following:

1.Benificiary's name

2. Date of order and start date, if different from date of order

3. Detailed description of the item being ordered

4. Route of administration

5. Frequency of use

6. Length of need

7. Treating practitioner's printed name and NPI

8. Treating practitioner's signature and date

• The CMN can be the DWO but must contain all the information listed above.
• In most cases , the detailed written order and medical record documentation must be obtained prior to delivery of the oxygen equipment.

Obstructive sleep apnea with use of home oxygen therapy:

For patients requiring the use of home oxygen with PAP device, both the PAP and oxygen policies must be met. The qualifying blood gas study must be performed during a titration study at a sleep lab facility making sure the pressure is at an optimal setting. The oximetry study performed during this titration shows oxygen saturation of 88 percent or less for five total minutes(does not have to be continuous) . There has to be a reduction in AHI/RDI reduced to less than or equal to an average of 10 events/hours or if the initial AHI/RDI was less than an average of 10 events per hour, then the titration demonstrates further reduction in AHI/RDI.

Recertification:

The following to be obtained with the recent CMN for either Group 1 or Group 2:

1. Re-evaluation by treating physician documenting patient is benefiting from the oxygen therapy and has shown improvement

2. Copy of most recent blood gas study (can be from the initial test, if that is the most recent) BUT should not be the normal practice.

GROUP 1 = Required after 12months of initial certification, which means the re-evaluation must occur within 90days prior to the date of recertification.

GROUP2 = Required after 12months of initial certification , which means the re-evaluation must occur between the 61st-90th day following the initial date.