Just Breathe

I have received more calls and emails than ever from the provider community about capped rental misunderstandings. Of course, questions about oxygen account for the largest number of the calls now that the regs have changed and patients will not assume ownership of their oxygen equipment after 36 months of rental.

Let's understand the capped rental model and know how to implement these changes within our corporate environment as well as understanding coverage guidelines.

Oxygen policies for coverage have not changed in coverage guidelines for reimbursement. Oxygen is covered for patients with hypoxia-related symptoms or severe lung disease. They either have to be a Group I or Group II patient to qualify.

A Group I patient has a PO2 of 55 mm hg or below, or an O2 saturation of 88 percent or below. A Group II patient has a PO2 of 56-59 mm hg, or an O2 saturation of 89 percent with the answer to one of Questions 7, 8 or 9 on the oxygen CMN being “yes.” These questions ask if the patient has a hematocrit greater than 56 percent; or if the patient has dependent edema due to congestive heart failure; or cor pulmonale or pulmonary hypertension.

You must also have audit procedures in place to ensure you have a copy of the physician progress notes, labs and documentation of one of these existing in the patient's medical records.

For all oxygen patients in pre-payment or post-payment audits, you are required to have a copy of the PO2 or O2 saturation in the patient's file to ensure the tests documented in Question 1 on the CMN are the actual test results on the report from the independent diagnostic testing facility or physician's office. Make sure if the PO2 is 55.5 mm hg that it is rounded to a 56 mm hg, which makes the beneficiary a Group II patient.

For Group I patients, you need an initial CMN for coverage. The test results must be within 30 days prior to the initial delivery date. Be sure your intake staff is educated in this matter.

One year from the initial date, you are required to obtain a one-year recertification CMN. If the length of need is 99 months (lifetime), then the patient does not have to be retested for coverage. But if the patient has been retested in the past year, then the most recent test result must be recoded on the CMN.

The patient must be seen by the treating physician within 90 days of the one-year recert date, and this must be documented in the patient's medical records. If your patient is not seen within 90 days prior to the recert date, then the patient's billing recert date will change to the date the patient is seen by the treating physician.