13.1 Oxygen and Oxygen Equipment
HCPCS Codes
The appearance of a code in this section does not necessarily indicate coverage.
| E0424 | Stationary compressed gaseous oxygen system, rental; includes contents (per unit), regulator, flowmeter, humidifier, nebulizer, cannula or mask, & tubing; 1 unit = 50 cubic ft. |
| E0425 | Stationary compressed gas system, purchase; includes regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing |
| E0430 | Portable gaseous oxygen system, purchase; includes regulator, flowmeter, humidifier, cannula or mask, and tubing |
| E0431 | Portable gaseous oxygen system, rental; includes regulator, flowmeter, humidifier, cannula or mask, and tubing |
| E0434 | Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing |
| E0435 | Portable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill adaptor |
| E0439 | Stationary liquid oxygen system, rental; includes use of reservoir, contents (per unit), regulator, flowmeter, humidifier, nebulizer, cannula or mask, & tubing; 1 unit = 10 lbs. |
| E0440 | Stationary liquid oxygen system, purchase; includes use of reservoir, contents indicator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing |
| E0441 | Oxygen contents, gaseous, per unit (for use with owned gaseous stationary systems or when both a stationary and portable gaseous system are owned; 1 unit = 50 cubic ft.) |
| E0442 | Oxygen contents, liquid, per unit (for use with owned liquid stationary systems or when both a stationary and portable liquid system are owned; 1 unit = 10 lbs.) |
| E0443 | Portable oxygen contents, gaseous, per unit (for use only with portable gaseous systems when no stationary gas or liquid system is used; 1 unit = 5 cubic ft.) |
| E0444 | Portable oxygen contents, liquid, per unit (for use only with portable liquid systems when no stationary gas or liquid system is used; 1 unit = 1 lb.) |
| E1390 | Oxygen concentrator, capable of delivering 85% or greater oxygen concentration at the prescribed flow rate |
Accessories
| A4615 | Cannula, nasal |
| A4616 | Tubing (oxygen), per foot |
| A4617 | Mouthpiece |
| A4619 | Face tent |
| A4620 | Variable concentration mask |
| A4621 | Tracheostomy mask or collar |
| A9900 | Miscellaneous supply, accessory and/or service component of another HCPCS code |
| E0455 | Oxygen tent, excluding croup or pediatric tents |
| E0555 | Humidifier, durable, glass or autoclavable plastic bottle type, for use with regulator or flowmeter |
| E0580 | Nebulizer, durable, glass or autoclavable plastic, bottle type, for use with regulator or flowmeter |
| E1353 | Regulator |
| E1355 | Stand/rack |
HCPCS Modifiers
| QE | Prescribed amount of oxygen is less than 1 liter per minute (LPM) |
| QF | Prescribed amount of oxygen is greater than 4 liter per minute (LPM) and portable oxygen is also prescribed |
| QG | Prescribed amount of oxygen is greater than 4 liters per minute (LPM) and portable oxygen is not prescribed |
| QH | Oxygen conserving device is being used with an oxygen delivery system |
Benefit Category
Durable Medical Equipments
Reference
Coverage Issues Manual 60-4
Definitions
The term blood gas study in this policy refers to either an arterial blood gas (ABG) test or an oximetry test. An ABG is the direct measurement of the partial pressure of oxygen (PO2) on a sample of arterial blood. The PO2 is reported as mm Hg. An oximetry test is the indirect measurement of arterial oxygen saturation using a sensor on the ear or finger. The saturation is reported as a percent.
Coverage and Payment Rules
For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this medical policy, "reasonable and necessary" are defined by the following coverage and payment rules.
Home oxygen therapy is covered only if all of the following conditions are met:
- 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's blood gas study meets the criteria stated below, and
- The qualifying blood gas study was performed by a physician or by a qualified provider or supplier of laboratory services, and
- The qualifying blood 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 blood 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 - i.e., not during a period of acute illness or an exacerbation of their underlying disease, and
- Alternative treatment measures have been tried or considered and deemed clinically ineffective.
Group I criteria include any of the following:
- An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent taken at rest (awake), or
- An arterial PO2 at or below 55 mm Hg, or an arterial oxygen saturation at or below 88 percent, taken during sleep for a patient who demonstrates an arterial PO2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89% while awake, or
- A decrease in arterial PO2 more than 10 mm Hg, or a decrease in arterial oxygen saturation more than 5 percent taken during sleep associated with symptoms or signs reasonably attributable to hypoxemia (e.g., cor pulmonale, "P" pulmonale on EKG, documented pulmonary hypertension and erythrocytosis), or
- An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent, taken during exercise for a patient who demonstrates an arterial PO2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89 percent during the day while at rest. In this case, oxygen is provided for during exercise if it is documented that the use of oxygen improves the hypoxemia that was demonstrated during exercise when the patient was breathing room air.
Initial coverage for patients meeting Group I criteria is limited to 12 months or the physician-specified length of need, whichever is shorter. (Refer to the Documentation section for information on recertification.)
Group II criteria include the presence of (a) an arterial PO2 of 56-59 mm Hg or an arterial blood oxygen saturation of 89 percent at rest (awake), during sleep, or during exercise (as described under Group I criteria) and (b) any of the following:
- Dependent edema suggesting congestive heart failure, or
- Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or "P" pulmonale on EKG (P wave greater than 3 mm in standard leads II, III, or AVF), or
- Erythrocythemia with a hematocrit greater than 56 percent.
Initial coverage for patients meeting Group II criteria is limited to 3 months or the physician specified length of need, whichever is shorter. (Refer to the Documentation section for information on recertification.)
Group III includes patients with arterial PO2 levels at or above 60 mm Hg or arterial blood oxygen saturations at or above 90 percent. For these patients there is a rebuttable presumption of noncoverage.
If all of the coverage conditions specified above are not met, the oxygen therapy will be denied as not medically necessary. Oxygen therapy will also be denied as not medically necessary if any of the following conditions are present:
- Angina pectoris in the absence of hypoxemia. This condition is generally not the result of a low oxygen level in the blood and there are other preferred treatments.
- Dyspnea without cor pulmonale or evidence of hypoxemia.
- Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities but in the absence of systemic hypoxemia. There is no evidence that increased PO2 will improve the oxygenation of tissues with impaired circulation.
- Terminal illnesses that do not affect the respiratory system.
The qualifying blood gas study must be performed by a physician or by a qualified Medicare Part A provider or a qualified laboratory. A supplier is not considered a qualified provider or a qualified laboratory for purposes of this policy. In addition, the qualifying blood gas study may not be paid for by any supplier. This prohibition does not extend to blood gas studies performed by a hospital certified to do such tests.
The qualifying blood gas study may be performed while the patient is on oxygen as long as the reported blood gas values meet the Group I or Group II criteria.
For Initial Certifications, the blood gas study reported on the Certificate of Medical Necessity (CMN) must be the most recent study obtained prior to the Initial Date indicated in Section A of the CMN and this study must be obtained within 30 days prior to that Initial Date.
For patients initially meeting Group I criteria, the most recent blood gas study prior to the thirteenth month of therapy must be reported on the Recertification CMN. For patients initially meeting Group I criteria, if the estimated length of need on the Initial CMN is less than lifetime and the physician wants to extend coverage, a repeat blood gas study must be performed within 30 days prior to the date of the Revised Certification.
For patients initially meeting Group II criteria, the most recent blood gas study which was performed between the 61st and 90th day following Initial Certification must be reported on the Recertification CMN. If a qualifying test is not obtained between the 61st and 90th day of home oxygen therapy, but the patient continues to use oxygen and a test is obtained at a later date, if that test meets Group I or II criteria, coverage would resume beginning with the date of that test. For patients initially meeting Group II criteria, if the estimated length of need on the Initial CMN is less than lifetime and the physician wants to extend coverage, a repeat blood gas study must be performed within 30 days prior to the date of the Revised Certification.
For any Revised CMN, the blood gas study reported on the CMN must be the most recent test performed prior to the Revised date.
A repeat blood gas study may be requested at any time at the discretion of the DMERC.
When both arterial blood gas (ABG) and oximetry tests have been performed on the same day under the same conditions (i.e., at rest/awake, during exercise, or during sleep), only report the ABG PO2 on the CMN. If the ABG PO2 result is not a qualifying value, home oxygen therapy will be denied as not medically necessary, regardless of the oximetry test result.
Portable Oxygen Systems
A portable oxygen system is covered if the patient is mobile within the home and the qualifying blood gas study was performed while at rest (awake) or during exercise. If the only qualifying blood gas study was performed during sleep, portable oxygen will be denied as not medically necessary.
If coverage criteria are met, a portable oxygen system is usually separately payable in addition to the stationary system. (See exception in Liter Flow Greater Than 4 PLM.)
Liter Flow Greater Than 4 LPM
If basic oxygen coverage criteria have been met, a higher allowance for a stationary system for a flow rate of greater than 4 liters per minute (LPM) will be paid only if a blood gas study performed while the patient is on 4 LPM meets Group I or II criteria. If a flow rate greater than 4 LPM is billed and the coverage criterion for the higher allowance is not met, payment will be limited to the standard fee schedule allowance.
If a patient qualifies for additional payment for greater than 4 LPM of oxygen and also meets the requirements for portable oxygen, payment will be made for either the stationary system (at the higher allowance) or the portable system (at the standard fee schedule allowance for a portable system), but not both. In this situation, if both a stationary system and a portable system are billed for the same rental month, the portable oxygen system will be denied as not separately payable.
Oxygen Contents
Oxygen contents are included in the allowance for rented oxygen systems. Stationary oxygen contents (E0441, E0442) are separately payable only when the coverage criteria for home oxygen have been met and they are used with a patient owned stationary gaseous or liquid system respectively. Portable contents (E0443, E0444) are separately payable only when the coverage criteria for home oxygen have been met and:
- the beneficiary owns a concentrator and rents or owns a portable system, or
- the beneficiary rents or owns a portable system and has no stationary system (concentrator, gaseous, or liquid).
If the criteria for separate payment of contents are met, they are separately payable regardless of the date that the stationary or portable system was purchased.
Oxygen Accessories
Accessories, including but not limited to, cannulas (A4615), humidifiers (E0555), masks (A4620, A4621), mouthpieces (A4617), nebulizer for humidification (E0580), oxygen conserving devices (A9900), regulators (E1353), transtracheal catheters (A9900), and tubing (A4616) are included in the allowance for rented systems. The supplier must provide any accessory ordered by the physician. Accessories are separately payable only when they are used with a patient-owned system that was purchased prior to June 1, 1989. Accessories used with a patient-owned system that was purchased on or after June 1, 1989 will be denied as noncovered.
Travel Oxygen
If a beneficiary travels out of their supplier's usual service area, it is the beneficiary's responsibility to arrange for oxygen during their travels. Medicare will only pay one supplier for oxygen during any one rental month.
Oxygen services furnished by an airline to a beneficiary are noncovered. Payment for oxygen furnished by an airline is the responsibility of the beneficiary and not the responsibility of the supplier.
Miscellaneous
The patient must be seen and evaluated by the treating physician within 30 days prior to the date of Initial Certification. The patient must be seen and re-evaluated by the treating physician within 90 days prior to the date of any Recertification.
Only rented oxygen systems (E0424, E0431, E0434, E0439, E1390RR) are eligible for coverage. Purchased oxygen systems (E0425, E0430, E0435, E0440, E1390NU, E1390UE) will be denied as noncovered.
Emergency or stand-by oxygen systems will be denied as not medically necessary since they are precautionary and not therapeutic in nature.
Respiratory therapists' services are noncovered under the DME benefit.
Coding Guidelines
For gaseous or liquid oxygen systems or contents, report one unit of service for one month rental. Do not report in cubic feet or pounds.
The appropriate modifier must be used if the prescribed flow rate is less than 1 LPM (QE) or greater than 4 LPM (QF or QG). These modifiers may only be used with stationary gaseous (E0424) or liquid (E0439) systems or with an oxygen concentrator (E1390). They must not be used with codes for portable systems or oxygen contents.
Claims for oxygen contents and/or oxygen accessories should not be submitted in situations in which they are not separately payable (see above).
Code ZZ010 (Transtracheal oxygen catheter for patient-owned equipment) is invalid for claim submission to the DMERC.
Codes E1405 and E1406 (Oxygen and water vapor enriching system) are invalid for claim submission to the DMERC. Codes E1377-E1385 (Oxygen concentrator, high humidity system) are invalid for claim submission to the DMERC.
Documentation
For an item(s) to be considered for coverage and payment by Medicare, the information submitted by the supplier must be corroborated by documentation in the patient's medical records that Medicare coverage criteria have been met. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, or records from other healthcare professionals. This documentation must be available to the DMERC upon request.
An order for the oxygen system and all related accessories which has been signed and dated by the treating physician must be kept on file by the supplier. A certificate of medical necessity (CMN) which has been signed and dated by the treating physician must be kept on file by the supplier. The CMN for home oxygen is HCFA Form 484. If the information on the CMN is sufficiently detailed, it may be used as an order. In addition to the order information that the physician enters in Section B, the supplier can use the space in Section C for a written confirmation of other details of the oxygen order or the physician can enter the other details directly-e.g. ,the means of oxygen delivery(cannula, mask, etc.) and the specifics of varying oxygen flow rates and/or noncontinuous use of oxygen.
If the claim is filed electronically, the information on the CMN must be transcribed exactly into the GX0, GX1, and GX2 records. (See DMEPOS National Standard Format Matrix for details.) If additional medical necessity information is included, it should be transcribed into the HA0 record. If a hard copy claim is submitted, a copy of the CMN must be attached.
An Initial, Recertification, or Revised CMN must be submitted to the DMERC in the situations described below. The Initial Date, Recertification Date, and Revised Date specified below refer to the dates reported in Section A of the CMN.
Initial CMN is Required
- With the first claim to the DMERC for home oxygen (even if the patient was on oxygen prior to Medicare eligibility or oxygen was initially covered by a Medicare HMO).
- When there has been a change in the patient's condition that has caused a break in medical necessity of at least 60 days plus whatever days remain in the rental month during which the need for oxygen ended. (This indication does not apply if there was just a break in billing because the patient was in a hospital, nursing facility, hospice, or Medicare HMO, but the patient continued to need oxygen during that time.)
- When the patient initially qualified in Group II, repeat blood gas studies were not performed between the 61st and 90th day of coverage, but a qualifying study was subsequently performed. The Initial Date on this new CMN may not be any earlier than the date of the subsequent qualifying blood gas study.
The blood gas study reported on the Initial CMN must be the most recent study obtained prior to the Initial Date and this study must be obtained within 30 days prior to that Initial Date.
Recertification CMN is Required
- Three months after Initial Certification (i.e., with the fourth month's claim) - if oxygen test results on the Initial Certification are in Group II. The blood gas study reported must be the most recent study which was performed between the 61st and 90th day following the Initial Date.
- Twelve months after Initial Certification (i.e., with the thirteenth month's claim) - if oxygen test results on the Initial Certification are in Group I. The blood gas study reported must be the most recent blood gas study prior to the thirteenth month of therapy.
- In other situations at the discretion of the DMERC. The blood gas study reported must be the most recent study which was performed within 30 days prior to the Recertification Date.
Revised CMN is Required
- When the prescribed maximum flow rate changes from one of the following categories to another: (a) less than 1 LPM, (b) 1-4 LPM, (c) greater than 4 LPM. If the change is from category (a) or (b) to category (c), a repeat blood gas study with the patient on 4 LPM must be performed within 30 days prior to the start of the greater than 4 LPM flow.
- When a portable oxygen system is added subsequent to Initial Certification of a stationary system. In this situation, there is no requirement for a repeat blood gas study unless the initial qualifying study was performed during sleep, in which case a repeat blood gas study must be performed while the patient is at rest (awake) or during exercise within 30 days prior to the Revised Date.
- When the length of need expires - if the physician specified less than lifetime length of need on the most recent CMN. In this situation, a revised blood gas study must be performed within 30 days prior to the Revised Date.
- When there is a new treating physician but the oxygen order is the same. In this situation, there is no requirement for a repeat blood gas study. Note: In this situation, the Revised CMN does not have to be submitted with the claim but must be kept on file by the supplier.
If there is a new supplier, that supplier must be able to provide the DMERC with an original CMN on request. (An original CMN is a CMN which has a physician's original signature on it. It is not necessarily an Initial CMN or the first CMN for that patient.) If the supplier obtains a new CMN, it would be considered a Revised CMN. In this situation, if the oxygen order is the same, the CMN does not have to be submitted with the claim.
Submission of a Revised CMN does not change the Recertification schedule specified above.
If the indications for a Revised CMN are met at the same time that a Recertification CMN is due, file the CMN as a Recertification CMN.
Miscellaneous
In the following situations, a new order must be obtained and kept on file by the supplier, but neither a new CMN nor a repeat blood gas study are required:
- Prescribed maximum flow rate changes but remains within one of the following categories: (a) less than 1 LPM, (b) 1-4 LPM, (c) greater than 4 LPM.
- Change from one type of system to another (i.e., concentrator, liquid, gaseous).
Refer to the Supplier Manual for more information on orders, Certificates of Medical Necessity, medical records, and supplier documentation.
Effective Date
Claims with dates of service on or after July 1, 2000.
This is a revision of a previously published policy.
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