Or. Admin. Code § 410-122-0203 - Oxygen and Oxygen Equipment
(1)
Indications and limitations of coverage and medical appropriateness: The
Division may cover home oxygen therapy services. Refer to Table 122-0203-1 and
the following guidelines:
(a) For children
under age 21 when the treating practitioner has determined oxygen services to
be medically appropriate; or
(b)
For adults age 21 years of age and older who are fully dual-eligible clients
(Medicare clients who are also eligible for Medicaid/Oregon Health Plan (OHP);
See definition in General Rules, OAR
410-120-0000), the Division may
cover oxygen services as follows:
(A) If
Medicare paid on the claim for the oxygen equipment, the Division may provide
reimbursement;
(B) If Medicare
denied payment on the claim for the oxygen equipment, the Division shall not
provide reimbursement in accordance with Medicare rules and
regulations;
(C) Refer to the
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
Supplemental Information for additional details on Medicare's reimbursement
limitation of 36 monthly rental payments;
(c) For adults 21 years of age and older who
are not eligible for Medicare (only eligible for Medicaid/OHP), PA is required
and all of the following conditions must be met:
(A) The treating practitioner has ordered and
evaluated the results of a qualifying blood gas study performed at the time of
need; and
(B) The client's blood
gas study meets the criteria stated below; and
(C) The qualifying blood gas study was
performed by a treating practitioner or by a qualified provider or supplier of
laboratory services; and
(D) The
provision of oxygen and oxygen equipment shall improve the client's
condition.
(d) Group I
criteria include any of the following:
(A) An
arterial partial pressure of oxygen (PO2) at or below 55 mm Hg or an arterial
oxygen saturation (e.g. peripheral pulse oximetry reading) at or below 88
percent taken at rest (awake) while breathing room air; or
(B) An arterial PO2 at or below 55 mm Hg, or
an arterial oxygen saturation (e.g. peripheral pulse oximetry reading) at or
below 88 percent, taken during sleep for a client who demonstrates an arterial
PO2 at or above 56 mm Hg or an arterial oxygen saturation (e.g. peripheral
pulse oximetry) at or above 89 percent while awake. In this instance, oxygen
and oxygen equipment is only necessary during sleep; or
(C) A decrease in arterial PO2 more than 10
mm Hg, or a decrease in arterial oxygen saturation (e.g. peripheral pulse
oximetry reading) more than 5 percent from baseline saturation, taken during
sleep and associated with symptoms of hypoxemia such as impairment of cognitive
processes and nocturnal restlessness or insomnia (not all-inclusive).In this
instance, oxygen and oxygen equipment is only necessary during sleep;
or
(D) An arterial PO2 at or below
55 mm Hg or an arterial oxygen saturation (e.g. peripheral pulse oximetry
reading) at or below 88 percent, taken during exercise for a client who
demonstrates an arterial PO2 at or above 56 mm Hg or an arterial oxygen
saturation (e.g. peripheral pulse oximetry reading) at or above 89 percent
during the day while at rest. In this instance, portable oxygen and oxygen
equipment is only necessary while awake and during exercise;
(e) Group II criteria include any
of the following:
(A) An arterial PO2 of 56-59
mm Hg or an arterial blood oxygen saturation of 89 percent; and any of the
following:
(i) Dependent edema suggesting
congestive heart failure; or
(ii)
Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary
artery pressure; gated blood pool scan, echocardiogram, or "P" pulmonale on EKG
(P wave greater than 3 mm in standard leads II, III, or AVF); or
(iii) Erythrocythemia with a hematocrit
greater than 56 percent;
(f) Group III criteria:
(A) Initial coverage of home oxygen therapy
and oxygen equipment is necessary for clients in Group III if all of the
following conditions are met:
(i) Absence of
hypoxemia defined in Group I and Group II above, and
(ii) A covered medical condition with
distinct physiologic, cognitive, and/or functional symptoms documented in
high-quality, peer-reviewed literature to be improved by oxygen
therapy;
(g)
For all the sleep oximetry criteria, the five minutes does not have to be
continuous;
(h) When both arterial
blood gas (ABG) and oximetry tests have been performed on the same day under
the same conditions (i.e., at rest/awake, during exercise, or during sleep),
the ABG result will be used to determine if the coverage criteria were
met;
(i) If an ABG test at
rest/awake is nonqualifying, but an exercise or sleep oximetry test on the same
day is qualifying, the oximetry test result shall determine coverage;
(j) Oxygen therapy and related services,
equipment or supplies are not considered medically appropriate or medically
necessary for any of the following:
(A) Angina
pectoris in the absence of hypoxemia. This condition is generally not the
result of a low oxygen level in the blood and there are other preferred
treatments;
(B) Dyspnea without cor
pulmonale or evidence of hypoxemia;
(C) Severe peripheral vascular disease
resulting in clinically evident desaturation in one or more extremities but in
the absence of systemic hypoxemia. There is no evidence that increased PO2
shall improve the oxygenation of tissues with impaired circulation;
(D) Terminal illnesses that do not affect the
ability to breathe;
(E) Emergency
or stand-by oxygen systems for clients who are not regularly using oxygensince
these services are precautionary and not therapeutic in nature;
(F) Topical hyperbaric oxygen chambers
(A4575);
(G) When furnished by an
airline (responsibility of the client);
(H) When provided/used outside the United
States and its territories.
(2) Testing Specifications:
(a) The term blood gas study in this policy
refers to both arterial blood gas (ABG) studies and pulse oximetry:
(A) An ABG is the direct measurement of the
PO2 on a sample of arterial blood. The PO2 is reported as mm Hg.
(B) An oximetry test is the indirect
measurement of arterial oxygen saturation (e.g. peripheral pulse oximetry
reading) using a sensor on the ear or finger. The saturation is reported as a
percent;
(C) An overnight oximetry
is a stand-alone pulse oximetry continuously recorded overnight. It does not
include oximetry results done as part of other overnight testing such as
polysomnography or home sleep testing;
(b) The qualifying blood gas study must be
one that complies with the Fiscal Intermediary, Local Carrier, or A/B Medicare
Administrative Contractor (MAC) policy on the standards for conducting the test
and is covered under Medicare Part A or Part B;
(c) All oxygen qualification testing must be
performed by a qualified practitioner or other medical professional qualified
to conduct oximetry:
(A) A DMEPOS provider is
not considered a qualified provider or a qualified laboratory for purposes of
this policy;
(B) Division shall not
accept blood gas studies either performed or paid for by a DMEPOS
provider;
(C) This prohibition does
not extend to blood gas studies performed by a hospital certified to do such
tests;
(d) When oxygen
is covered based on an oximetry study obtained during exercise, there must be
documentation of three oximetry studies performed within the same testing
session in the client's medical record:
(A)
Testing at rest without oxygen;
(B)
Testing during exercise without oxygen; and
(C) Testing during exercise with oxygen
applied, to demonstrate the improvement of the hypoxemia;
(e) All three tests must be performed in
person by a treating practitioner or other medical professional qualified to
conduct exercise oximetry testing;
(f) Only the qualifying test value (i.e.,
testing during exercise without oxygen) is used for qualification. All three
(3) tests must be available upon request by the Division;
(g) The qualifying blood gas study may be
performed while the client is on oxygen as long as the reported blood gas
values meet the Group I or Group II criteria.
(3) Obstructive Sleep Apnea (OSA),
Polysomnography and Home Sleep Tests:
(a) Home
oxygen therapy and oxygen equipment with a PAP device is covered when criteria
for both Oxygen and Oxygen Equipment and Positive Airway Pressure (PAP) devices
for the treatment of Obstructive Sleep Apnea are met; and
(b) For clients with OSA, it is required that
the OSA be appropriately and sufficiently treated before oxygen saturation
results obtained during sleep testing are considered qualifying for oxygen
therapy and oxygen equipment. This means that the OSA must be sufficiently
treated such that the underlying condition resulting in hypoxemia is unmasked.
This must be demonstrated before the oxygen saturation results are obtained
during polysomnography are considered qualifying for oxygen therapy and oxygen
equipment; and
(c) For clients with
OSA, a qualifying oxygen saturation test may only occur during a titration
polysomnographic study (either split night or stand-alone). The titration PSG
is one in which all of the following criteria are met:
(A) The titration is conducted over a minimum
of two (2) hours; and
(B) During
titration:
(i) The AHI/RDI is reduced to less
than or equal to an average of ten (10) events per hour; or
(ii) If the initial AHI/RDI was less than an
average of ten (10) events per hour, the titration demonstrates further
reduction in the AHI/RDI; and
(C) Nocturnal oximetry conducted for the
purpose of oxygen therapy qualification may only be performed after optimal PAP
settings have been determined and the client is using the PAP device at those
settings; and
(D) The nocturnal
oximetry conducted during the PSG demonstrates an oxygen saturation of less
than or equal to 88 percent;
(d) Overnight oximetry performed as part of
home sleep testing or as part of any other home testing is not considered
eligible to be used for qualification for reimbursement of home oxygen and
oxygen equipment.
(4)
Portable Oxygen Systems:
(a) A portable oxygen
system may be covered if the client is mobile within the home for Groups I and
II, and the qualifying blood gas study was performed while at rest (awake) or
during exercise. If the only qualifying blood gas study was performed during
sleep, portable oxygen is not covered;
(b) If coverage criteria are met, a portable
oxygen system is usually separately payable in addition to the stationary
system. See exception in (6) below;
(c) If a portable oxygen system is covered,
the DMEPOS provider must provide whatever quantity of oxygen the client uses;
the reimbursement is the same, regardless of the quantity of oxygen
dispensed.
(5) Liter
flow greater than 4 LPM:
(a) If initial oxygen
coverage criteria for Group 1, II, and III have been met, the Division will pay
a higher allowance for a stationary system for a flow rate of greater than 4
LPM only when:
(A) Basic oxygen coverage
criteria have been met; and
(B) A
blood gas study performed while the client is on 4 LPM meets Group I or II
criteria;
(b) Payment is
limited to the standard fee schedule allowance if a flow rate greater than 4
LPM is billed and the coverage criteria for the higher allowance are not
met.
(6) Documentation
Requirements: The DMEPOS provider shall maintain and provide record of the
face-to-face encounter and written order/prescription in addition to the
qualifying documentation which supports conditions of coverage and testing
requirements as specified in this rule are met;
(a) The written order for home oxygen must be
completed, signed, and dated by the treating practitioner, not the DMEPOS
provider, prior to delivery. The DMEPOS provider may use a written confirmation
of other details of the oxygen order, or the treating practitioner can enter
the other details directly, such as the means of oxygen delivery (cannula,
mask, etc.) and the specifics of varying oxygen flow rates and/or
non-continuous use of oxygen. There must be a treating practitioner's signed
and dated order for each item billed. Items billed before a signed and dated
order has been received by the DMEPOS provider must be submitted with an EY
modifier added to each affected Healthcare Common Procedure Coding System
(HCPCS) code;
(b) The following
special instructions apply to replacement equipment:
(A) Initial date should be the date that the
replacement equipment is initially needed. This is generally understood to be
the date of delivery of the oxygen equipment;
(B) A treating practitioner's order is needed
to reaffirm the medical necessity of the item for replacement of an
item;
(C) Claims for the initial
rental month (and only the initial rental month) must have the RA modifier
(Replacement of DME item) added to the HCPCS code for the equipment when there
is replacement due to reasonable useful lifetime or replacement due to damage,
theft, or loss;
(D) Claims for the
initial rental month must include a narrative explanation of the reason why the
equipment was replaced and supporting documentation must be maintained in the
DMEPOS provider's files;
(c) In the following situations, a new order
must be obtained and kept on file by the DMEPOS provider; however, a repeat
blood gas study are required:
(A) Prescribed
maximum flow rate changes but remains within one of the following:
(i) Less than 1 LPM;
(ii) 1-4 LPM;
(iii) Greater than 4 LPM;
(B) Change from one type of
stationary system to another (i.e., concentrator, liquid, gaseous);
(C) Change from one type of portable system
to another (i.e., gaseous or liquid tanks, portable concentrator, transfilling
system).
(7)
Oxygen contents:
(a) The Division allowance
for rented oxygen systems includes oxygen contents necessary for one
month;
(b) Stationary oxygen
contents (E0441, E0442) are separately payable only when the coverage criteria
for home oxygen have been met and they are used with a client-owned stationary
gaseous or liquid system respectively;
(c) Portable contents (E0443, E0444) are
separately payable only when the coverage criteria for home oxygen have been
met and:
(A) The client owns a concentrator
and rents or owns a portable system; or
(B) The client rents or owns a portable
system and has no stationary system (concentrator, gaseous, or
liquid);
(C) If the criteria for
separate payment of contents are met, they are separately payable regardless of
the date that the stationary or portable system was purchased;
(d) Refer to Table 122-0203-2 for
oxygen contents that may be reimbursable for dual-eligible clients.
(8) Oxygen accessory items:
(a) The allowance for rented systems
includes, but is not limited to, the following accessories:
(A) Transtracheal catheters
(A4608);
(B) Cannulas
(A4615);
(C) Tubing
(A4616);
(D) Mouthpieces
(A4617);
(E) Face tent
(A4619);
(F) Masks (A4620,
A7525);
(G) Oxygen tent
(E0455);
(H) Humidifiers (E0550,
E0555, E0560);
(I) Nebulizer for
humidification (E0580);
(J)
Regulators (E1353);
(K) Stand/rack
(E1355);
(b) The DMEPOS
provider must provide any accessory ordered by the practitioner;
(c) Accessories are not separately
payable.
(9) Billing for
miscellaneous oxygen items:
(a) Only rented
oxygen systems (E0424, E0431, E0434, E0439, E1390RR, E1405 RR, E1406RR,
E1392RR) are considered for coverage;
(b) For gaseous or liquid oxygen systems or
contents, report one unit of service for one month rental. Do not report in
cubic feet or pounds;
(c) Use the
appropriate modifier if the prescribed flow rate is less than 1 LPM (QE) or
greater than 4 LPM (QF or QG). Division only accepts these modifiers with
stationary gaseous (E0424) or liquid (E0439) systems or with an oxygen
concentrator (E1390, E1391). Do not use these modifiers with codes for portable
systems or oxygen contents;
(d) Use
Code E1391 (oxygen concentrator, dual delivery port) in situations in which two
clients are both using the same concentrator. In this situation, this code must
only be requested for one of the clients;
(e) For E1405 and E1406 (oxygen and water
vapor enriching systems), products must be coded as published by the Pricing,
Data Analysis and Coding (PDAC) Contractor by the Centers for Medicare and
Medicaid Services;(f) Code E1392 describes a portable oxygen concentrator
system. Use E1392 when billing the Division for the portable equipment add-on
fee for clients using lightweight oxygen concentrators that can function as
both the client's stationary equipment and portable equipment. A portable
concentrator:
(A) Weighs less than 10
pounds;
(B) Is capable of
delivering 85 percent or greater oxygen concentration; and
(C) Is capable of providing at least two
hours of remote portability at a 2 LPM order equivalency;
(g) Contact the PDAC for guidance on the
correct coding of these items.
(10) Table 122-0203-1, Oxygen and Oxygen
Equipment.
(11) Table 122-0203-2,
Oxygen Contents.
Notes
Tables referenced are available from the agency.
To view attachments referenced in rule text, click here to view rule.
Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
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