Oxygen Coverage & Documentation Requirements (A/B MAC & DME … · 2020. 10. 20. · October 5,...

October 5, 2020

Oxygen Coverage &

Documentation Requirements

A collaborative webinar presented by the

A/B and DME Medicare Administrative Contractors

October 5, 2020

DisclaimerThe A/B and DME MAC Provider Outreach and Education (POE) staff have produced this material as an informational reference for providers furnishing services in our contract jurisdictions to Medicare beneficiaries.

Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services (CMS) website at http://www.cms.gov.

As a reminder, CMS does not allow recording of education opportunities such as this.

© 2020 Copyright, CGS Administrators, LLC2

http://www.cms.gov/

October 5, 2020

Participants CGS Administrators, LLC: http://www.cgsmedicare.com

First Coast Service Options, Inc.: http://www.fcso.com/

National Government Services: http://ngsmedicare.com/

Noridian Healthcare Solutions, LLC: http://www.noridianmedicare.com/

Novitas Solutions: https://www.novitas-solutions.com/

Palmetto GBA: http://www.palmettogba.com/

WPS Government Health Administrators: https://www.wpsgha.com/


http://www.cgsmedicare.com/

http://www.fcso.com/

http://ngsmedicare.com/

http://www.noridianmedicare.com/

https://www.novitas-solutions.com/

http://www.palmettogba.com/

https://www.wpsgha.com/

TODAY’S PRESENTATION

© 2020 Copyright, CGS Administrators, LLC

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October 5, 2020

ObjectiveIncrease understanding for treating practitioners of clinical documentation requirements for their Medicare patients who require home oxygen therapy.


October 5, 2020

Helpful AcronymsAcronym Description IOM Internet Only ManualLCD Local Coverage DeterminationLPM Liters per minuteMm Hg Millimeters of Mercury NCD National Coverage DeterminationRUL Reasonable Useful LifetimeSAT Oxygen SaturationSNF Skilled Nursing FacilityWOPD Written Order Prior to Delivery


https://www.cms.gov/apps/acronyms/

https://www.cms.gov/apps/acronyms/

October 5, 2020

Agenda Coverage Criteria

Testing Requirements

Concurrent Use of Oxygen and PAP

Certificate of Medical Necessity

Relocation and Travel

Comprehensive Error Rate Testing (CERT)

COVID-19 Waivers and Flexibilities Impact

Resources

Questions


October 5, 2020

Coverage CriteriaNational Coverage Determination (NCD) - 240.2

Local Coverage Determination (LCD) - L33797

Policy Article (PA) - A52514

Standard Documentation Requirements Policy Article (A55426)


October 5, 2020

Oxygen Coverage Criteria Home Oxygen is reasonable and necessary only if all the following conditions

are met per LCD L33797:• The treating practitioner has determined that the beneficiary has a severe lung

disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy, and

• The beneficiary’s blood gas study meets the coverage criteria, and

• The qualifying blood gas study was performed by a practitioner or by a qualified provider or supplier of laboratory services, and

• The qualifying blood gas study was obtained under the requirements specified in the LCD, and

• Alternative treatment measures have been tried or considered and deemed clinically ineffective

The blood gas study must be the most recent study obtained within 30 days prior to the Initial Certification Date


October 5, 2020

Alternative Treatment Measures -Clarification

Q: What is considered alternative treatment measures before the oxygen is ordered?

A: Many disease conditions have standard treatment regimens associated with them. This criterion, together with the requirement that testing be done while the patient is in their chronic, stable state means that the usual treatment modalities need to be optimized before oxygen becomes eligible for reimbursement.


October 5, 2020

Home Oxygen – NotReasonable and Necessary

Angina pectoris in absence of hypoxemia

Dyspnea without cor pulmonale or evidence of hypoxemia

Severe peripheral vascular disease in absence of systemic hypoxemia

Terminal illnesses that do not affect respiratory system


October 5, 2020

NCD Conditions Which Oxygen May Be Covered

Severe lung disease, such as chronic obstructive pulmonary disease, diffuse interstitial lung disease, whether of known or unknown etiology; cystic fibrosis, bronchiectasis; widespread pulmonary neoplasm; or

Hypoxia-related symptoms or findings that might be expected to improve with oxygen therapy.

• Examples of symptoms and findings are pulmonary hypertension, recurring congestive heart failure due to chronic cor pulmonale, erythrocytosis, impairment of cognitive process, nocturnal restlessness, and morning headache


October 5, 2020

Qualifying Blood Gas StudyMedicare’s oxygen coverage criteria divides beneficiaries into three coverage groups

Group I: Arterial PO2 is 55 mm Hg or less or saturation is 88% or less

Group II: Arterial PO2 is 56 - 59 mm Hg or saturation is 89% and:

• Dependent edema suggesting congestive heart failure, or

• Pulmonary hypertension or cor pulmonale, or

• Erythrocythemia with a hematocrit greater than 56 percent

Group III: Arterial PO2 is 60 mm Hg or greater or saturation is 90% or greater

– For these beneficiaries there is a rebuttable presumption of non-coverage.


October 5, 2020

Portable Oxygen Beneficiary must be mobile within home

Qualifying study performed at rest or during exercise

• Study performed during sleep – not reasonable and necessary

Separately payable if coverage criteria met

• Reimbursement is same regardless of quantity dispensed


October 5, 2020

Testing Requirements


October 5, 2020

Testing Specifications:Qualifying Study

The qualifying study may be performed:

At rest

• Awake: sitting or lying down

During sleep

• Overnight Sleep Oximetry performed in hospital or at home

• Titration Polysomnogram used for beneficiaries with concurrent OSA

During exercise

• Considered as either formal exercise or exertion while performing Activities of Daily Living (ADL)

– Requires a series of 3 tests done during a single testing session:

– At rest, off oxygen-showing a non-qualifying result

– Exercising, off oxygen-showing a qualifying result

– Exercising on oxygen, showing improvement in test results obtained while exercising off oxygen


October 5, 2020

Testing Specifications: Timing of Testing


Inpatient Hospital Stay Outpatient

Closest to, but no earlier than two (2) days prior to the hospital discharge date

Last qualifying test prior to discharge

Must be performed while the beneficiary is in a chronic stable state

Not during acute illness or exacerbation of underlying disease

October 5, 2020

Qualified Testing Providers

Oxygen qualification testing may only be performed by providers designated as qualified to perform such testing. Testing done by non-qualified entities is not valid for purposes of qualification for Medicare reimbursement for home oxygen.

For purposes of meeting the "qualified provider" criterion, this policy uses a determination based upon two criteria:

• Whether the test performed meets the applicable requirements for Medicare billing of the specific test, and

• The entity that performed the test meets the applicable requirements for Medicare billing of the specific test.

Note: This does not require that the specific test be actually billed and/or paid, only that the testing entity meet the requirements necessary to perform and bill Medicare for the actual test.


October 5, 2020

Overnight Oximetry Studies Overnight sleep oximetry may be performed in a facility or at home.

Stand-alone overnight pulse oximetry

Tamper proof

Capable of downloading data that allows documentation of duration of oxygen desaturation below specified value

For all the sleep oximetry criteria, the five (5) minutes qualifying period does not have to be continuous and the lowest value during the five (5) minute period should be recorded on the CMN.

Overnight oximetry performed as part of home sleep testing or as part of any other home testing is not considered to be eligible to be used as qualification for reimbursement of home oxygen and oxygen equipment.


October 5, 2020

Concurrent Use Oxygen and PAP

Obstructive Sleep Apnea (OSA)

Positive Airway Pressure (PAP)

Polysomnography (PSG)


October 5, 2020

Overnight Oximetry,OSA AND PSG

Testing must be done in chronic stable state

Both oxygen LCD and PAP LCD must be followed

OSA sufficiently treated and lung disease unmasked


October 5, 2020

Overnight Oximetry,OSA AND PSG (2)

Overnight oximetry during home sleep test not eligible to be used for oxygen qualification

Testing may only occur during a Titration Study and

• Minimum 2 hours

• During titration, specific reduction in AHI/RDI criteria met

– Reduced to an average of ten events per hour; or

– If initial less than average ten events per hour, demonstration of further AHI/RDI reduction

• Only performed after optimal PAP settings determined

• Nocturnal oximetry conducted during PSG shows <88% for 5 minutes


October 5, 2020 25 © 2020 Copyright, CGS Administrators, LLC

Titration Example

PAPCm H2O

Total Sleep Time (min) TIB (min)

SleepEff % # Hypopneas

#Central Apneas

# Obstructive Apneas AHI

Lowest SPO2

Time O2 88% or under

(min)

0Baseline 124 208 59.6 79 0 49 61.9 86 70

5 23.5 28 83.9 16 0 2 46 89 10

6 13 13.5 96.3 8 0 3 50.8 88 9

7 26 26 100 6 0 4 23.1 88 22

8 17.5 18 97.2 9 0 1 34.3 87 16

9 18.5 23 80.4 8 0 6 42.2 89 7

10 13.5 13.5 100 3 0 0 13.3 81 13.5

11 122 172 70.9 4 0 7 5.4 88 83

Total minutes 358 502

October 5, 2020

Standard Written Order


October 5, 2020

Standard Written OrderFor dates of service on and after January 01, 2020, an SWO must be communicated to the supplier prior to claim submission and must contain all of the following:

Beneficiary's name or Medicare Beneficiary Identifier (MBI)

Order Date

General description of the item

• The description can be either a general description (e.g., wheelchair or hospital bed), a HCPCS code, a HCPCS code narrative, or a brand name/model number

• For equipment - In addition to the description of the base item, the SWO may include all concurrently ordered options, accessories or additional features that are separately billed or require an upgraded code (List each separately)

• For supplies – In addition to the description of the base item, the DMEPOS order/prescription may include all concurrently ordered supplies that are separately billed (List each separately)

Quantity to be dispensed, if applicable

Treating practitioner name or NPI

Treating practitioner's signature


October 5, 2020

Requirements of New Orders New order is required when:

• For all claims for purchases or initial rentals;

• If there is a change in the DMEPOS order/prescription e.g. quantity;

• On a regular basis (even if there is no change in the order/prescription) only if it is so specified in the documentation section of a particular medical policy;

• When an item is replaced;

• When there is a change in the supplier, and the new supplier is unable to obtain a copy of a valid order/prescription for the DMEPOS item from the transferring supplier.


October 5, 2020

Certificate of Medical Necessity (CMN)


October 5, 2020

Initial CMN First claim to DME MAC

• Testing and practitioner evaluation within 30 days of initial date

Break in need during 36-month rental period

• Testing and practitioner evaluation within 30 days of initial date

Replacement due to RUL

• No new testing or new practitioner visit required per LCD

Replacement due to irreparable damage, theft, or loss of originally dispensed equipment

• No new testing or new practitioner visit required


October 5, 2020

Recertification Group I patients – 12 months after initial

• Most recent qualifying test prior to 13th month

Group II patients – 3 months after initial

• Most recent qualifying test between 61st – 90th day

Other requirements for above:

• Re-evaluation within 90 days prior to recertification

• Above criteria not met, but use continues, coverage resumes when requirements are met

Recertification for replacement equipment:

• Same timeframes apply

• Repeat testing and re-evaluation not required

• Use most recent qualifying value and test date


October 5, 2020

Revised CMN Change in flow rate category

• Less than 1 liter per minute (LPM)

• 1 - 4 LPM

• Greater than 4 LPM

Length of need expired

Portable added to stationary

Stationary added to portable

New treating practitioner - oxygen order is the same

New supplier does not have the prior CMN

Revised CMN does not change recertification schedule


October 5, 2020

Other CMN Notes CMN Sections B and D completed by practitioner

• Signature and date stamps are not acceptable for use on CMNs

• Form CMS-484 (02/20): https://med.noridianmedicare.com/documents/2230703/6501021/CMS-484+Oxygen/24e203f1-1851-4e9f-95e0-cc98185bd587

Misc. changes not requiring new CMN or testing

• Flow rate changes but remains in same category

• Change of modality

• Does require new order


https://med.noridianmedicare.com/documents/2230703/6501021/CMS-484+Oxygen/24e203f1-1851-4e9f-95e0-cc98185bd587

October 5, 2020

Making Changes to CMN Two options when making changes to CMN

• Draw line through error

– Treating practitioner must initial and date correction

– Must have similar capability for electronic CMN

• Complete new CMN

Whiteout not acceptable


October 5, 2020

CMN CompletionSection A


October 5, 2020

CMN Completion (2)

Section B - May be completed by non-practitioner clinician or practitioner employee but must be reviewed and signed by treating practitioner


October 5, 2020

Oxygen CMN #5Impact on Billing Liter Flow

Beneficiaries with a single flow rate for day and night

• Practitioner reports prescribed flow rate on CMN #5

Beneficiaries with differing day and night flow rates

• Practitioner reports highest prescribed liter flow on CMN #5

• Supplier calculates average


October 5, 2020

CMN Completion (3)

Sections C

Section D


October 5, 2020

Travel Beneficiary responsible for airline oxygen services

Beneficiary responsible for services provided outside United States and its territories


October 5, 2020

Reasonable Useful Lifetime (RUL) Supplier’s responsibility ends when RUL reached

Beneficiary has 3 options:

• Supplier picks up equipment and discontinues servicing beneficiary

• Supplier provides replacement equipment and begins new 36-month cap

– Treating practitioner must complete a new initial CMN

» No requirement for physician visit or testing

• Supplier continues servicing existing equipment and bills only for contents and M&S


October 5, 2020

Oxygen Beneficiaries Entering Medicare

Beneficiary seeking rental or replacement oxygen must meet these requirements:

1. Blood gas study must be most recent study obtained within 30 days prior to Initial Date

• There is an exception to 30-day test requirement for beneficiaries who were started on oxygen while enrolled in a Medicare HMO and transition to FFS. Blood gas study does not have to be obtained 30 days prior to Initial Date, but must be most recent qualifying test obtained while on HMO

2. Beneficiary must be seen and evaluated by treating practitioner within 30 days prior to date of initial certification


October 5, 2020

Orders vs. Medical Record A prescription is not considered as part of the medical record. Medical

information intended to demonstrate compliance with coverage criteria may be included on the prescription but must be corroborated by information contained in the medical record. (PIM 5.2.3)


October 5, 2020

Comprehensive Error Rate Testing (CERT)


October 5, 2020

Comprehensive Error Rate Testing (CERT)2019 Improper Payment Rates and Projected Improper Payment

https://www.cms.gov/files/document/2019-medicare-fee-service-supplemental-improper-payment-data.pdf


Service Type Improper Payment Rate Projected Improper Payment Amount

Overall 7.25% $28.91 BPart A Providers (excluding Hospital Inpatient Prospective Payment System (IPPS))

8.07% $13.34 B

Part B Providers 8.64% $8.66 BDMEPOS 30.7% $2.44 BHospital IPPS 3.57% $4.47 B

https://www.cms.gov/files/document/2019-medicare-fee-service-supplemental-improper-payment-data.pdf

October 5, 2020

Common CERT Oxygen Errors Missing treating practitioner’s clinical records to support beneficiary’s

condition that requires oxygen use and that beneficiary continues to need and use supplemental home oxygen proximal to billed date of service (DOS)

Missing signed and dated order from practitioner that reflects change in oxygen liter flow rate


October 5, 2020

Common CERT Oxygen Errors 2

Missing copy of qualifying oxygen saturation study that applies to conditions stated on CMN

Missing treating practitioner's re-evaluation within 90 days of recertification CMN supporting beneficiary's lung disease or hypoxia-related symptoms that improve with oxygen therapy


October 5, 2020

DME CERT Task ForceMedtrade Spring 2020

Error Breakdown

Medical RecordsOrders and CMNsBilling and NPIDelivery


October 5, 2020

COVID-19 Waivers and Flexibilities Impact


October 5, 2020

Append CR modifier

Narrative “COVID-19”

Clinical Indication Non-Enforcement

Waiver/Flexibility Summary CRClinical Indications for Certain Respiratory, Home Anticoagulation Management, Infusion Pump and Therapeutic Continuous Glucose Monitor national and local coverage determinations

In the interim final rule with comment period (CMS-1744-IFC and CMS-5531-IFC) CMS states that clinical indications of certain national and local coverage determinations will not be enforced during the COVID-19 public health emergency. CMS will not enforce clinical indications for respiratory, oxygen, infusion pump and continuous glucose monitor national coverage determinations and local coverage determinations.

X


October 5, 2020

Face-to-Face EncountersWaiver/Flexibility Summary CR

Face-to-face and In-person Requirements for national and local coverage determinations

In the interim final rule with comment period (CMS-1744-IFC) CMS states that to the extent a national or local coverage determination would otherwise require a face-to-face or in-person encounter for evaluations, assessments, certifications or other implied face-to-face services, those requirements would not apply during the COVID-19 public health emergency.

X


Append CR modifier

Narrative “COVID-19”

October 5, 2020

Resources and Reminders


October 5, 2020

NCD and LCD References National Coverage Determination for Oxygen and Oxygen Equipment

• https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf

Local Coverage Determinations

• https://www.cgsmedicare.com

• https://www.noridianmedicare.com

Related Policy Articles

• https://www.cgsmedicare.com

• https://www.noridianmedicare.com


https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf

https://www.cgsmedicare.com/

https://www.noridianmedicare.com/

https://www.cgsmedicare.com/

http://www.noridianmedicare.com/

October 5, 2020

Noridian Healthcare SolutionsDME MAC Jurisdiction A Resources

Website: https://med.noridianmedicare.com/web/jadme

IVR, Supplier Contact Center, and Telephone Reopenings: 1.866.419.9458

Noridian Medicare Portal: https://med.noridianmedicare.com/web/jadme/topics/nmp

Documentation Checklists: https://med.noridianmedicare.com/web/jadme/policies/documentation-checklists

Clinician’s Corner: https://med.noridianmedicare.com/web/jadme/policies/clinicians-corner


https://med.noridianmedicare.com/web/jadme

https://med.noridianmedicare.com/web/jadme/topics/nmp

https://med.noridianmedicare.com/web/jadme/policies/documentation-checklists

https://med.noridianmedicare.com/web/jadme/policies/clinicians-corner

October 5, 2020

CGS Administrators, LLCDME MAC Jurisdiction B Resources

Website: http://www.cgsmedicare.com/jb

IVR Unit: 1.877.299.7900

myCGS Web Portal: http://www.cgsmedicare.com/jb/mycgs/index.html

Customer Service: 1.866.590.6727

Telephone Re-openings: 1.844.240.7490

Documentation Checklists: https://cgsmedicare.com/jb/mr/documentation_checklists.html

Physician’s Corner: https://cgsmedicare.com/jb/mr/phys_corner.html


http://www.cgsmedicare.com/jb

http://www.cgsmedicare.com/jb/mycgs/index.html

https://cgsmedicare.com/jb/mr/documentation_checklists.html

https://cgsmedicare.com/jb/mr/phys_corner.html

October 5, 2020

CGS Administrators, LLCDME MAC Jurisdiction C Resources

Website: http://www.cgsmedicare.com/jc

IVR Unit: 1.866.238.9650

myCGS Web Portal: http://www.cgsmedicare.com/jc/mycgs/index.html

Customer Service: 1.866.270.4909

Telephone Re-openings: 1.866.813.7878

Documentation Checklists: https://cgsmedicare.com/jc/mr/documentation_checklists.html

Physician’s Corner: https://cgsmedicare.com/jc/mr/phys_corner.html


http://www.cgsmedicare.com/jc

http://www.cgsmedicare.com/jc/mycgs/index.html

https://cgsmedicare.com/jc/mr/documentation_checklists.html

https://cgsmedicare.com/jc/mr/phys_corner.html

October 5, 2020

Noridian Healthcare SolutionsDME MAC Jurisdiction D Resources

Website: https://med.noridianmedicare.com/web/jddme/

IVR, Supplier Contact Center and Telephone Reopenings: 1.877.320.0390

Noridian Medicare Portal: https://med.noridianmedicare.com/web/jddme/topics/nmp

Documentation Checklists: https://med.noridianmedicare.com/web/jddme/policies/documentation-checklists

Clinician’s Corner: https://med.noridianmedicare.com/web/jddme/policies/clinicians-corner


https://med.noridianmedicare.com/web/jddme/

https://med.noridianmedicare.com/web/jddme/topics/nmp

https://med.noridianmedicare.com/web/jddme/policies/documentation-checklists

https://med.noridianmedicare.com/web/jddme/policies/clinicians-corner

October 5, 2020

Questions? Thank you for attending this A/B and

DME MAC collaborative education.


Oxygen Coverage & Documentation Requirements (A/B MAC & DME … · 2020. 10. 20. · October 5,...

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