Last Modified: 11/3/2020
Location: FL, PR, USVI
Business: Part B
The following is a quick reference guide for physicians and non-physician practitioners concerning Medicare’s coverage of oxygen and oxygen equipment.
• For Medicare to consider coverage of oxygen and oxygen equipment, the beneficiary must have a severe lung disease, such as chronic obstructive pulmonary disease (COPD) or cystic fibrosis, or hypoxia-related symptoms corresponding to a condition that might be expected to improve with oxygen therapy (examples [not all-inclusive] such as recurring congestive heart failure [CHF] due to chronic cor pulmonale or pulmonary hypertension).
• The beneficiary’s medical record must document the disease and show the condition’s progression and the need for oxygen therapy.
• The beneficiary has had a qualifying blood gas study, which can be either an oximetry test or an arterial blood gas test.
• This information must be in the beneficiary’s medical record. The values must correspond to the information on the Certificate of Medical Necessity (CMN).
• The blood gas study can be administered while the beneficiary is awake or asleep (under certain circumstances).
• Outpatient testing must be done while the beneficiary is in a chronic stable state and not during a period of acute illness or exacerbation of the underlying condition or disease. Medicare will also consider a blood gas study done within two days of discharge from a hospital. Medicare will consider coverage for both stationary and portable oxygen systems if the blood gas study is done while the beneficiary is awake or during exercise. Portable oxygen systems are not eligible for coverage if the qualifying blood gas test is performed during sleep (i.e., an overnight oximetry test).
• Other alternative treatments have been tried or considered and deemed clinically ineffective.
• The beneficiary’s medical record must show what other treatments have been used or considered and why oxygen therapy is the next medically necessary step in treating the beneficiary’s condition.
• There must be a provider encounter with the beneficiary and a qualifying blood gas study taken within 30 days of the initial need for oxygen therapy.
• This is a requirement found in the local coverage determination (LCD) that physicians and suppliers must abide by.
• The physician or non-physician practitioner must complete, sign and date an Oxygen Certificate of Medical Necessity (CMN), Centers for Medicare & Medicaid Services (CMS) Form 484, before the company providing the oxygen equipment can file oxygen claims to the Medicare program.
• The use of the CMN is a CMS requirement. The physician must sign and date Section D of the CMN, but a staff member may complete Section B. The durable medical equipment (DME) supplier will complete Sections A and C – usually before sending it to the physician’s office. Completing the CMN in a timely manner will allow the DME supplier to submit claims to Medicare.
As a reminder, these quick tips do not encompass all guidelines surrounding oxygen and oxygen equipment but provide a quick overview of the LCD requirements. Medical professionals ordering oxygen should review the oxygen and oxygen equipment LCD found on one of the DME Medicare administrative contractor (MAC) websites below:
DME MAC Jurisdiction A (CT, DE, MA, ME, MD, NH, NH, NY, PA, RI, VT, District of Columbia) -- Clinician’s Corner
DME MAC Jurisdiction C (AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, SC, TN, TX, VA, WV, Puerto Rico, U.S. Virgin Islands) --
DME MAC Jurisdiction D (AK, AZ, CA, HI, ID, IA, KS, MO, MT, NE, NV, ND, OR, SD, UT, WA, WY, American Samoa, Guam, Northern Mariana Islands) -- Clinician’s Corner
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