BALTIMORE — CMS issued additional guidance on oxygen billing Jan. 27, and, while the instruction came three weeks after the 36-month oxygen cap took effect Jan. 1, it did bring a few small sighs of relief.
"It definitely answered lots of questions that were out there," said Lisa Smith, health care attorney for Brown & Fortunato, Amarillo, Texas. "This was probably the best news that providers have seen. When you stack this up against what else has been coming out, this is definitely the silver lining."
Beleaguered by the cap and a 9.5 percent reimbursement cut that also went into effect Jan. 1, providers have been clamoring for information about requirements under the post-cap payment rules — included in CMS' 1,459-page 2009 Physician Fee Schedule — they have protested as unworkable.
Smith said one of the major pluses of the guidance is that it allows providers to start billing for portable oxygen even if the stationary unit has not capped out.
"I think that is really going to help out providers," she said. "The other thing is that the way they are calculating the five-year [useful life period], it basically starts when the initial oxygen was placed on the patient and it doesn't reset if you change modalities or you have to swap out equipment or the patient changes providers."
The new guidance also makes it clear that providers do not need to deliver oxygen contents every month in order to continue billing on a monthly basis. However, Smith noted, "CMS has set a cap of three months for contents to be delivered at one time, and suppliers need to be aware of that."
Jason Rogers, vice president of Care Medical in Athens, Ga., said he was pleased by another feature of the guidance. "We finally got a little bit of positive [news], and that is that we don't have to have a retest," said Rogers. "That is a huge burden that is not placed on us. That would have really complicated the ability to provide replacement oxygen equipment."
While the guidance clarified several issues, Smith said, "unfortunately, there are still some questions that CMS is going to have to clarify." For example, she pointed out, "They say that you have to have a CMN for the replacement equipment, but it is not clear to me whether this is a recertification CMN or a new initial CMN."
Smith said she has broached the question to CMS officials and hopes to have an answer within a week or so. Until that issue is cleared up, however, providers really can't bill for replacement equipment, she said.
"The other thing we need clarification on is the proof of delivery when you are replacing equipment at the end of its useful life," she noted.
The guidance requires that providers have proof-of-delivery documentation in their files attesting that the oxygen equipment has been in use for at least five years. This could be a stumbling block for those who are servicing a new patient and would not necessarily have access to a delivery ticket from when the initial equipment was first delivered. Smith has also asked CMS if there is other documentation that would be acceptable but has not yet heard back.
While the new guidance may prove helpful, providers and others in the sector are still campaigning to get the 36-month cap repealed and, in the long run, reform Medicare's oxygen benefit.
Toward that end, the American Association for Homecare recently unveiled its oxygen overhaul plan which, among other things, would repeal the cap, change the status of oxygen entities from "suppliers" to "providers" and exempt oxygen from competitive bidding. It would also base reimbursement on a case-mix adjusted system, under which providers' payments would change based on patient factors such as ambulation level, liter flow and modality. (See AAHomecare Unveils Oxygen Overhaul Plan, HomeCare Monday, Jan. 12.)
While most in the industry agree the benefit needs to be reworked, some state associations have said the AAHomecare plan does not contain enough specifics to gain their unqualified support.
"This is a proposal that we were excited about when we heard about its development and we really wanted to like," said John Shirvinsky, executive director of the Pennsylvania Association of Medical Suppliers. "We like parts of it very much. Where it starts to break down for us is in the details of how you pay for [the benefit] and the whole tiered payment structure. We really have no details on that. And if there are no details, why are we even talking about this?
"We really need to reform the oxygen payment," Shirvinsky continued. "We are absolutely behind naming them 'providers' instead of 'suppliers.' But how the numbers work out after that point is a head-scratcher."
Care Medical's Rogers, who is president of the Georgia Association of Medical Equipment Services, agreed. "The general idea of having recognition and a service component is a wonderful move in the right direction," he said. But GAMES cannot support the plan because, among other things, it lacks specificity and immediacy, he said.
Michael Reinemer, AAHomecare's vice president, communications and policy, acknowledged some details are lacking. "The question isn't whether or not oxygen should be fixed," he said, "it's exactly what does it mean for an oxygen provider in terms of lots of specifics. All of those details haven't been completely worked out."
The oxygen cap needs to be repealed swiftly, he said, but that is complicated by the fact that Congress wants to see a long-term plan before legislators move on the cap. "We are getting pushback from Congress asking for a long-term solution," Reinemer said.
He noted AAHomecare is working with state associations toward "something that everybody can live with," and said the plan is to be further discussed at the organization's Feb. 11 Washington fly-in. "The most pressing topic at the fly-in is how do providers deal with this post-cap reimbursement," he said. "There are lots of questions."
The AAHomecare plan isn't the only one in the works. Rogers said he is attempting to put together a plan. And the Big Sky Association for Medical Equipment Services, which covers Idaho, Montana and Wyoming, is also working on a plan that has garnered the interest of the seven-state Midwest Association for Medical Equipment Services, according to Tim Pederson, president and CEO of WestMed Rehab, Rapid City, S.D., and MAMES president.
"The MAMES board of directors has come out in support of concepts envisioned in the conceptual plan by the Big Sky association called the 'Oxygen Flip Plan,'" he said. "It's not finalized yet, but we like what we hear so far. From what we understand, when you crunch the numbers, the savings are substantial for CMS and it will provide stability for the industry at the same time. That is something we need."
View CMS' Jan. 27 oxygen guidance, titled "Medicare Billing Requirements and Policies for Replacement of Oxygen Equipment and Oxygen Contents".
For Smith's answers to the most common questions about the post-cap rules, see "Your Post-O2 Cap Questions Asked and Answered" in this issue.
For information on AAHomecare's Feb. 11 fly-in, visit the "Homecare on Capitol Hill" Day event page.
View AAHomecare's summary of CMS' oxygen policy payment provisions.
