The “bread and butter” for many HME providers is respiratory business.
When a referral source calls to send your company an oxygen referral, the person who answers your phone must be knowledgeable about the documentation and qualification issues for oxygen and related supplies. Otherwise, you may not get the information you need to ensure the claim will be reimbursed.
A good suggestion is to develop a separate intake form for each piece of equipment, which will enable the intake coordinator to obtain the proper information. Basically, you will be completing a “confirmation of verbal order” to attach to the certificate of medical necessity, quoting back to the physician the information you received at the time of intake.
What qualifies a Medicare patient for home oxygen therapy?
A Group I patient must have a PO2 (blood gas level) of 55 or below, or an O2 Sat (oxygen saturation) of 88 percent or below. Ask for a copy of the lab results to be faxed so you can verify that the patient qualifies. If an O2 Sat were 88.5 percent, for example, that would round up to 89 percent, making this person a Group II patient and changing the reimbursement results.
A Group II patient will have a PO2 between 56 and 59, or an O2 Sat of 89 percent, as well as one of the three following criteria:
(a) Dependent edema due to congestive heart failure; or (b) A cor pulmonale or pulmonary hypertension documented by a pulmonale on an EKG or by an endocardiogram, gated blood pool scan or direct pulmonary artery pressure measurement; or (c) Hematocrit greater then 56 percent. (The answer to Questions 8, 9 or 10 on the CMN must be “yes.”)
A Group III patient does not qualify for home oxygen therapy per Medicare guidelines.
A patient qualifies for a portable oxygen system as long as he is ambulatory within the home environment and has not been tested during sleep. Question 3 on the CMN asks how the patient was tested: at rest, during exercise or during sleep. If the patient was tested during sleep, he will qualify only for the concentrator. If at a later date the patient is tested other than at sleep, and the physician wishes for the patient to have a portable system, you will be required to obtain a revised CMN to add this equipment.
You must also obtain information documenting when the patient was tested, per Question 2 on the CMN. You must know whether the patient was tested in a chronic stable state as an outpatient, or if the patient was tested within 48 hours prior to hospital discharge. To qualify for home oxygen therapy, a patient must not have been tested when in a chronic state, such as in an emergency room.
For Question 4 on the CMN, verify that the facility where the qualifying test was performed is qualified as an Independent Diagnostic Testing Facility (ITDF). If it is not, you will find yourself returning that reimbursement money to the DMERC in a post-payment audit.
To answer Question 6 on the oxygen CMN, you will need the liter flow per minute that the physician is prescribing for the patient.
If you have a patient on more than 4 LPM (liters per minute) of oxygen, the patient must be tested on 4 LPM of oxygen, and the test result must be documented for Question 7 on the CMN. You will then need to add appropriate modifiers if the patient qualifies to be on five or more liters, and Medicare will reimburse 50 percent more on the allowable amount for code E1390 (oxygen concentrator).
As always, call the SADMERC with any coding or fee schedule questions, and see the Spring Advisory on your DMERC Web site for qualification issues.
And remember that beginning April 1, the new HCPCS code K0671 — portable oxygen concentrator — will be reimbursable. (The only product approved at this time for that HCPCS code is the Inogen One.)
There are many other updates coming out daily. Keep current, and let's get the right intake process started.
Jane Bunch is CEO of Kennesaw, Ga.-based JB&CS. A reimbursement specialist, Bunch delivers educational seminars worldwide, helps develop corporate compliance plans, and serves as a consultant for fraud and abuse cases. She can be reached at 678/445-1221 or via e-mail at BILLHME@aol.com.
