Not too long ago, taking referrals and billing for oxygen products and services was something most of us felt we could do in our sleep. But that was before the “audit atrocities of 2012.” These audits are a combination of pre-payment and post-payment audits by the DME/MACs as well as the CERT contractors. Many HMEs report they have had to add a significant number of staff hours to be able to respond to the requests in a timely manner and, of course, to keep revenue coming in the door. The following areas are still the most problematic:
- Patient testing does not meet intent of the LCD;
- Having language from the medical record that demonstrates other methods that have been tried and failed;
- Documentation lacking from the medical record of patient use and need within CMS timeframe;
- Evidence of prescriber evaluation that is specific to addressing the need for oxygen.
This column will focus on the two areas that, in my experience, have caused the most strife for HME providers: evidence of prescriber evaluation that is specific to addressing the need for oxygen, and having language from the medical record that demonstrates other methods that have been tried and failed.
When a patient is referred to an HME provider following discharge from a hospital, many providers “assume” that the patient has certainly been evaluated for medical necessity for providing oxygen therapy by the prescriber. That assumption is where the problems begin. It is recommended you ask—preferably before you provide the oxygen product to the patient—to see documentation to prove that the evaluation is contained in the record.
A note from the doctor’s order sheet to “provide home oxygen at two liters by nasal prongs,” even accompanied by valid test results (Spo2 or ABG), is not an assessment. Instead, look to the progress notes for some description of why the patient continues to need oxygen. Seek statements that show the patient’s COPD has not been effectively managed by other interventions. These can include therapies such as beta agonists, anticholinergics, methylyzanthines and/or repeated antibiotic or antiviral therapies. The GOLD (Global Obstructive Lung Disease) recommendations address when these other therapies should have been added to the patient treatment plan. Other treatment plans such as completion of pulmonary rehab programs (formal or otherwise) and/or smoking cessation programs also should prove to be great supporting documentation. Basically, look for the medical record to tell a story as to why the oxygen needs to be added to the patient plan of care.
When patients are referred to your HME from doctors’ clinics, it is not uncommon for the HME to be given a diagnosis code for hypoxia. While this is often a paid claim, receiving an ADR letter (Additional Document Review) means someone is going to have to clearly explain what is causing the hypoxia and what has been done prior to implementing oxygen for the patient. This particular diagnosis code can send up some red flags, as it must be demonstrated that whatever is wrong with the patient, the condition is expected to improve with the addition of oxygen.
Some patients, for example, have very low oxygen levels such as those seen in anemic hypoxemia. However, oxygen is not going to improve that particular medical condition. Only an intervention that affects the hemoglobin molecule (such as blood transfusion) can remedy this. Another example of this could occur when patients have nocturnal pulse oximetery that shows low saturation levels. There should be notes that communicate what the oxygen desaturation results from. The patient could instead have obstructive sleep apnea and the airway is closing off at various times throughout the night. Delivering oxygen into a blocked airway will have minimal therapeutic effects, but applying pressure to that airway to keep it open (CPAP) often results in enough improvement that added oxygen is not warranted.
These are examples of when CMS wants to see that the patient has been thoroughly evaluated and the condition assessed by a qualified prescriber. In the CMS medical policy it states that the qualified prescriber can be the patient’s doctor, advanced practice nurse or physician’s assistant. But no matter who it is the record must, as they say, “tell the story.”
