• Oxygen Info.

    CMS requires that for Specified Covered Items  payment may  only  be made  if  a physician has communicated to the supplier a written order for the item before the delivery of the item.

    For many items of DME, a physician must document that a physician, a physician assistant (PA), a nurse practitioner (NP), or a clinical  nurse specialist (CNS)  has had  a face-to-face encounter with the beneficiary pursuant to that order. The encounter must occur during the six months  prior to the written order for each item.

    The  patient’s medical record must contain sufficient documentation of the patient’s medical condition to substantiate the
    necessity for the type and quantity of items ordered  and must be signed by the ordering physician.

    Documentation Requirements

    •  Duration of patient’s condition ❑ Clinical course
    •  Prognosis
    •  Nature and extent of functionallimitations
    • Other Therapeutic interventions and results


    Key Items to Address

    • Why does the patient require the item?
    • Do the physical examination findings support the need for the item
    • Signs and symptoms that indicate the need for the item.
    • Diagnoses that are responsible for these signs and symptoms.
    • Other diagnoses that may relate to the need for the item.

    Documentation Tips

    • The information must not be recorded in vague and subjective terms.
    • The information must provide objective measures, tests or observations.
    •  Each medical record is expected to be individualized to the unique patient.

    Coverage Criteria Specific Oxygen and Respiratory Equipment

    Home Oxygen is covered only when the following criteria are met and documented in the patient’s medical record:

    1. The treating physician has determined that the patient has a severe lung disease or hypoxia-related symptoms that might be expected to improve with oxy-gen therapy, and
    2. The patient’s blood gas study meets re-quired criteria, and
    3. The qualifying blood gas study was performed by a physician or by a qualified provider or supplier of laboratory services, and
    4. The qualifying 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 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, and
    5. Alternative treatment measures have been tried or considered and deemed clinically ineffective.

    Specific Documentation Requirements

    Documentation for initial coverage requires information in the medical record showing:

    • Evidence of qualifying test results done within 30 days before the initial date of service.
    • Evidence of an in-person visit with a treating physician done within 30 days before the initial date of service.

    Coverage of home oxygen therapy requires documentation in the medical record that the patient has:

    •  A severe underlying lung disease, such as chronic obstructive pulmonary disease, diffuse interstitial disease, cystic fibrosis, bronchiectasis, widespread neoplasm or hypoxia-related symptoms or findings that might be expected to improve with oxygen therapy; and
    • The patient is not experiencing an exacerbation of their underlying lung disease described above or other acute condition(s) impacting the patient’s oxygen saturation;
    • For patients with concurrent PAP therapy, the qualifying oxygen saturation test is performed following optimal treatment of the OSA.

    A portable oxygen system requires documentation in the patient’s medical record that the patient is mobile within the home and the qualifying blood gas study was performed while at rest or during exercise.