CPAP Documentation & Guidelines | Oxygen Documentation & Guidelines
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Medicare Dear Physician Letters | Medicare Policies | Quick Script
Oxygen Documentation & Guidelines
Oxygen therapy is covered for patients when the treating physician has determined the patient has a severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy.
Medical records supporting that the patient has been seen within 30 days prior to ordering the oxygen and the treating physician has considered alternative treatment measures and demeed them clinically ineffective; AND
The patient has had a blood gas study that meets one of the following criteria:
The qualifying blood gas study was performed by a physician or by a qualified provider or supplier of laboratory services (blood gas studies performed by a supplier are not acceptable); AND
The qualifying blood gas study was obtained under one of the following conditions:
- Performed during an inpatient hospital stay, no earlier than 2 days prior to the hospital discharge date, and was the last test obtained prior to discharge; OR
- Was not performed during an inpatient hospital stay and was performed while the patient was in a chronic stable state, not during a period of acute illness or exacerbation of their underlying disease; AND
The qualifying blood gas study was the most recent study obtained prior to the initial date indicated in Section A of the CMN and this study was obtained within 30 days prior to the Initial State; AND
The patient was seen and evaluated by the treating physician within 30 days prior to the date of the initial certification; AND
Alternative measures have been tried or considered and deemed clinically ineffective.
Group I criteria include any of the following:
- At rest (awake but sitting or lying down), the arterial PO2 is at or below 55mm Hg or the arterial oxygen saturation is at or below 88%.
- While awake, the patient's arterial PO2 is greater than or equal to 56mm Hg or the arterial oxygen saturation is greater than or equal to 89% but for at least 5 minutes during sleep, the arterial PO2 falls to 55mg Hg or less or the arterial oxygen saturation to 88% or less.
- During sleep, there is a decrease in the arterial PO2 of more than 10mm Hg or decrease in the arterial oxygen saturation of more than 5% from baseline saturation for at least 5 minutes and the decrease in PO2 or O2 saturation is associated with the symptoms or signs reasonably attributable to hypoxemia.
- At rest, the patient's arterial PO2 is greater than or equal to 56mm Hg or the arterial oxygen saturation is greater than or equal to 89% on room air but during exercise the arterial PO2 falls to 55mm Hg or below or the arterial oxygen saturation is 88% or below and oxygen administration improves hypoxemia and medical record includes all of the following:
- Blood gas study performed at rest without oxygen;
- Blood gas study performed during exercise without oxygen; and
- Blood gas study performed during exercise with oxygen applied that demonstrated improvement of the hypoxemia.
[Note: All three qualifying blood gas study readings should be taken during a single testing session. The exercise blood gas reading is the number that should be recorded on the CMN. However, all three readings must be recorded in the medical record. Medical records must support the patient is mobile within the home.]
Group II criteria include the presence of (a) arterial PO2 of 56-59mm Hg or an arterial blood oxygen saturation of 89% at rest (awake), during sleep for at least 5 minutes, 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 3mm in standard leads II, III, or AVF); or
- Erythrocythemia with a hematocrit greater than 56%.
Initial coverage for patients meeting Group II criteria is limited to 3 months or the physician specified length of need, whichever is shorter. The patient would have to be retested between the 61st and 90th day following Initial Certification.
Documentation of Continued Medical necessity is required; the patient must be seen within 90 days prior to the recertification date of the CMN for Group I patients. Group II patients must be tested between the 61st and the 90th day after the date of the initial CMN. All patients after the recertification should be seen at least every 12 months and medical records updated to show continued need for the oxygen.
The physician's signature on the medical record must meet signature requirements:
http://www.cgsmedicare.com/jC/PUBS/NEWS/2010/0410/COPE12069.HTML
NHIC, Corp.. Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11468). Retrieved July 9, 2012 from http://www.medicarenhic.com/dme/medical_review/mr_lcds/mr_lcd_current/L11468_2011-10-01_PA_2011-10.pdf
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