When you entered the home care field, you probably had images of providing care and comfort to those in need. Most of us never imagined that in order to assure access to care for those we serve, we would need to be just as cognizant of words like “transmittal,” “advisory opinion” and “bulletin” as we are of the words “concentrator,” “conserver” and “transfill.”
Although sifting through policy, transmittals and Office of Inspector General opinions is not something we look forward to, it must be done. And that information must then be disseminated to those sending orders for the patient's care.
One important transmittal has made it easier for HME suppliers and physicians to obtain oxygen-qualifying overnight oximetry test results.
CMS Transmittal 173, published in August 2005, allows the HME supplier (or other shipping entity) to deliver a sealed, tamper-proof oximeter to the patient's home on behalf of an Independent Diagnostic Testing Facility. This process can only happen after the patient's physician has ordered an overnight oximetry test.
CMS is very clear that the physician — not the provider — must request the test. However, providers are permitted to contact the physician regarding the need for testing in certain circumstances, for example: when recertification is due, when testing is required due to change in insurance, when the initial test was invalid, i.e., not done with patient in a chronic stable state, or within two days of discharge from a hospital.
Providers who have patients enrolled in disease management-type programs may continue to communicate with the physician in regard to findings on ordered clinical assessments.
A recent OIG advisory opinion strongly states that HME companies may not perform free pre-screening oximetry tests for patients. It is also prohibited for a company to set up oxygen for free while waiting for a qualifying test.
In the event that the patient must be set up on oxygen without the qualifying test, the provider must give the patient an Advanced Beneficiary Notice advising that the services provided will not be covered because they do not meet the payment coverage rules set by Medicare.
The policy issued by CMS states that the beneficiary may self-administer home- based overnight oximetry tests under the direction of the IDTF. Because the beneficiary self-administers the test, the IDTF must provide clear, written instructions on proper operation of the equipment, and provide a mechanism for the beneficiary to address questions to the IDTF.
The IDTF will send results only to the ordering physician. In the event that the HME provider is currently furnishing oxygen, or has a release that is compliant with HIPAA privacy standards signed by the beneficiary or his/her representative, the provider may obtain a copy of the test results directly from the IDTF. It is important that the provider obtain copies of test results and keep them in the patient file, whether the tests are completed by an IDTF, a physician's office or a hospital.
According to guidelines issued by CMS, testing that is done by a home health agency does not constitute a valid qualifying test. The only exception would be an uncommon situation where the HHA is also a qualified lab or IDTF.
Testing done while the patient is in a skilled nursing facility is considered valid as long as the facility has maintained its qualifications for laboratory services.
Getting appropriate medical care paid for should be of a primary interest to all. Patients who worry about having coverage for services are more inclined to refuse those services. Often, this results in a decline in health status and increased costs to the health care system as a whole.
It is important that those of us who provide care take the time to care about those pesky things like transmittal notices, advisory opinions and bulletins.
References
John W. Salyer, “Neonatal and Pediatric Pulse Oximetry,” Respiratory Care, August 2003
Jeffrey S. Baird, Esq., “Oxygen Rules Clarification: What the Provider Can and Cannot Do,” The MED Group E-Conference, November 2006
Kevin M. Fussel, MD, et al, “Assessing Need for Long-Term Oxygen Therapy: A Comparison of Conventional Evaluation and Measures of Ambulatory Oximetry Monitoring,” Respiratory Care, February 2003
Charlotte Bell, MD, “Understanding Contemporary Pulse Oximetry,” Clinical Window Web Journal, June 2005
Neil R. MacIntyre, MD, FAARC, “Long-Term Oxygen Therapy: Conference Summary,” Respiratory Care, February 2000
Qualifying Patients for Home Ambulatory Oxygen
Evaluation for long-term oxygen therapy involves a resting Spo2 or Pao2, and the lowest Spo2 during some form of exertion, to identify patients who suffer substantial desaturation during activities of daily living. For payment coverage under Medicare's policy, exercise or exertion is not defined.
Morrison et al studied 20 COPD patients receiving LTOT using 24 hours of continuous oximetry. The study found that 11 patients who did not have resting hypoxia (Spo2 >90%) spent an average of 22 percent of the 24-hour period with Spo2 <90%, demonstrating that some patients with normal resting Spo2 spend a substantial amount of time hypoxemic!
Recognizing that certain COPD patients are often hypoxic while exercising or simply performing activities of daily living, many physicians choose portable oxygen therapy as part of the plan of care. CMS supports this decision by providing payment as long as certain criteria are met.
The primary issue, according to the Oxygen Medical Policy published by CMS, is not the extent of the exercise performed but whether the patient is also tested during exercise with oxygen. Medicare wants to see evidence that the hypoxemia is improved with oxygen applied.
The Oxygen Medical Policy, in fact, requires documentation of three oxygen studies in the patient's medical record: testing at rest without oxygen, testing during exercise without oxygen and testing during exercise with oxygen applied.
Only the results from the test during exercise without oxygen are entered on the CMN. The other results must be in the patient's medical records, preferably of both the oxygen supplier and physician, and must be available to the Medicare Administrative Contractor (the DME MAC) on request.
Documentation and physician oversight of the three oxygen studies is good medicine, as it provides a baseline for ongoing evaluation of the patient with pulmonary disease.
With more than 25 years of respiratory experience in both institutional and home care settings, Kelly J. Riley, CRT, RCP, is director, National Respiratory Network, for The MED Group, Lubbock, Texas. Previously, she served as COO for At Home Medical (formerly Via Christi at Home) in Ponca City, Okla. Riley can be reached by e-mail at kriley@medgroup.com or by phone at 580/762-3500.
