I have received more calls and emails than ever from those in the HME provider community about misunderstandings involving capped rentals. Of course most of those questions have come in since the new home oxygen regulations regarding the 36-month rental cap and the post-cap payment rules took effect on January 1 this year.
Let's make sure you understand the capped rental model and that you know how to implement these changes within your corporate environment.
First, remember that oxygen policy coverage guidelines have not changed for reimbursement. Oxygen is covered for patients with hypoxia-related symptoms or severe lung disease. Beneficiaries have to be either a group I or group II patient to qualify.
A group I patient has a PO2 of 55 mmHg or below, or an O2 saturation of 88 percent or below. A group II patient has a PO2 of 56-59 mmHg or an O2 saturation of 89 percent, with the answers to one of Questions 7, 8 or 9 being “yes” on the oxygen certificate of medical necessity. These questions ask if the patient has a hematocrit greater than 56 percent, a dependent edema due to congestive heart failure or cor pulmonale or pulmonary hypertension.
You must also have audit procedures in place to ensure you have a copy of the physician progress notes, labs and documentation of one of these conditions in the patient's medical records.
For all oxygen patients in pre-payment or post-payment audits, you are required to have a copy of the PO2 or O2 saturation in the patient's file to ensure the tests documented in Question 1 on the CMN are the actual test results on the report from the independent diagnostic testing facility or physician's office.
For results where the PO2 is 55.5 mmHg, round up to a 56 mmHg. This means the beneficiary will be a group II patient. In many of the audits I am currently reviewing, the test results do not match what is recorded on the CMN so, needless to say, you are going to hear CMS say, “Show me the money!” You can prevent this needless mistake by auditing more closely internally.
For group I patients, you need an initial CMN for coverage. The test results must be within 30 days prior to the initial delivery date. (Make certain your intake staff is educated on this detail.)
One year from the initial date, you are required to obtain a one-year recertification CMN. If the length of need is 99 months (lifetime), then the patient does not have to be retested for coverage. But if the patient has been retested in the past year, then the most recent test result must be recorded on the CMN.
The patient must be seen by the treating physician within 90 days prior to the recert date on the CMN, and this must be documented. I suggest documenting this on the CMN in Section C so you have the physician's signature verifying this is an accurate date for the patient's last visit.
If the patient is not seen by the treating physician within 90 days, then your recert date will change to the date the patient is seen following the “original” recert date. If you are currently not obtaining this information, you should begin immediately.
Once the patient has been on continuous oxygen for five years, the 36-month capped rental can start over if the patient elects.
Make sure you have documentation from your patients stating it is their choice and they wish to start over on the capped rental — and that they understand the 20 percent copay amount for the next 36 months. Also, read the policy carefully to make sure you understand the documentation required to bill the oxygen with appropriate modifiers.
In addition, because of the changes to the oxygen reimbursement policy, it is vital your intake and billing staff check the IVR line to see how long a beneficiary has been paid on oxygen claims before you take a change-of-provider patient.
Read policy updates and stay on top of all changes as they occur, because we all know there will be more to come!
Read more Billing & Reimbursement columns.
Jane Bunch is president/CEO of Jane's Healthcare Consulting based in Marietta, Ga. A reimbursement specialist, Bunch delivers educational seminars, helps develop corporate compliance plans and serves as a consultant for fraud and abuse cases. She can be reached at 770/366-0644 or at billhme@aol.com.
