Working Down Denials

Meet Medical Necessity for Oxygen

Medicare requires layers of documentation
by Sarah Hanna

For many providers, oxygen is the lifeblood of their revenue cycle. But Medicare is making it increasingly difficult to keep the oxygen cash flow in a positive state.

We have CERT, pre-pay audits, Additional Documentation Requests (ADRs) and also more complicated redeterminations and reconsiderations to validate a patient’s medical need. 

Remember the good old days when a Certificate of Medical Necessity (CMN) sufficed as proof of medical necessity? Unfortunately, our new reality involves chart note documentation from referral sources.

Providers should have the following documentation to prove medical necessity of claims: 

  • A copy of the most recent Certificate of Medical Necessity (CMN) dated before service started
  • The treating physician’s detailed written order for DMEPOS items. CMN can serve as a detailed written order if it is sufficiently completed.
  • If the Date of Service (DOS) is before the signature date on the Detailed Written Order (DWO), proof of a dispensing order must be submitted.
  • Copy of the beneficiary’s most recent arterial blood gas PO2 and/or oxygen saturation test value reported on the CMN
  • Documentation of a physician office visit before the initial date of service; the physician’s office visit must be within 30 days of the initial CMN date or within 90 days of the recertification CMN date.
  • Valid Proof of Delivery
  • Contemporaneous—within the past six months—chart notes proving on-going need for oxygen after recertification

When responding to audits and documentation requests, many providers fall short on chart notes regarding the physician office visit before the initial date of service. This needs to occur within 30 days of the initial CMN date or within 90 days of the recertification CMN date.

Also pay attention to visit notes from the physician because many providers are being denied on medical necessity redeterminations and reconsiderations because they lack the 30- and 90-day visit notes proving a patient was assessed and requires oxygen.

In a recent oxygen prepayment audit completed by NHIC Corp., the Jurisdiction A DME MAC, 56.3 percent of the denied claims had problems because of visit notes.  Problems included:

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