by Raquel Shumway
January 22nd, 2019
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.
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.
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
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.
Table 3: Group 3 Criteria:
May be covered when patients are enrolled in a CMS approved clinical trial.
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)