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Oxygen and Oxygen Equipment

Initial Certification

  • Documentation of verbal order (if item is dispensed based on a verbal order) that contains:
    • Description of the item
    • Name of the beneficiary
    • Name of the physician
    • Start date of the order
  • Valid written order that contains:
    • Beneficiary’s name
    • The item(s) to be dispensed
    • The means of oxygen delivery
    • The specifics of varying oxygen flow rates and/or non-continuous use of oxygen
    • A narrative diagnosis and/or ICD-9 diagnosis code
    • Length of need
    • The treating physician’s signature
    • The date the treating physician signed the order
    • The start date of the order – only required if the start date is different from the signature date
  • CMN (the CMN may act as a substitute for a written order if it is sufficiently detailed)
  • Copy of the qualifying ABG or pulse oximetry report referenced on the CMN
  • Proof of delivery

Supporting Medical Records

Include medical records that support the patient meets the basic coverage criteria specified in the Coverage and Payment Rules section of the oxygen and oxygen equipment local coverage determination (LCD).

  • Documentation the patient was seen and evaluated by the treating physician within 30 days prior to the date of initial certification, and
  • The patient has a severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy, and
  • Alternative treatment measures have been tried or considered and deemed clinically ineffective, and
  • The qualifying blood gas study was obtained under one of the following conditions:
    • Performed during an inpatient hospital stay no earlier than two days prior to the hospital discharge date and was the last test obtained prior to discharge, or
    • Was not performed during an inpatient hospital stay and was performed while the patient was in a chronic stable state, and
  • The qualifying blood gas study was the most recent study obtained prior to the Initial date indicated in Section A of the CMN and this study was obtained within 30 days prior to the initial date, and
  • The qualifying blood gas study meets group I coverage criteria:
    • At rest, the arterial PO2 is at or below 55 mm Hg or the arterial oxygen saturation is at or below 88 percent, or
    • While awake, the patient’s arterial PO2 is = 56 mm Hg or the arterial oxygen saturation is = 89 percent, and during sleep, the arterial PO2 falls to = 55 mm Hg or the arterial oxygen saturation is = 88 percent for at least five minutes, or
    • During sleep, there is a decrease in the arterial PO2 of more than 10 mm Hg or a decrease in the arterial oxygen saturation of more than five percent for at least five minutes, and
    • the decrease in PO2 or O2 saturation is associated with symptoms or signs reasonably attributable to hypoxemia, or
    • At rest, the patient’s arterial PO2 is = 56 mm Hg or the arterial oxygen saturation is = 89 percent on room air but, during exercise, the arterial PO2 falls to = 55 mm Hg or the arterial oxygen saturation is = 88 percent and, oxygen administration improves the hypoxemia
    • Note: The blood gas reading obtained during exercise, while breathing room air, is the number that should be recorded on the CMN; however, all three readings should be on file, or
  • The qualifying blood gas study meets group II coverage criteria
    • The arterial PO2 is 56–59 mm Hg or the arterial blood oxygen saturation is 89 percent at rest (awake) or during sleep for at least five minutes or during exercise (as described under group I criteria), and
    • The beneficiary has dependent edema suggesting congestive heart failure, or
    • The beneficiary has pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or “P” pulmonale ore EKG (P wave greater than 3 mm in standard leads II, III, or AVF), or
    • The beneficiary has erythrocythemia with a hematocrit greater than 56 percent

Group I Recertification

(Required 12 months after initial certification)

  • Recertification CMN
  • Copy of blood gas study (should be the most recent test prior to the 13th month of therapy)
  • Medical records documenting that the patient was seen and reevaluated by the treating physician within 90 days prior to the date of the recertification

Group II Recertification

(Required three months after initial certification)

  • Recertification CMN
  • Copy of blood gas study (should be the most recent test performed between the 61st and 90th day)
  • Medical records documenting that the patient was seen and re-evaluated by the treating physician within 90 days prior to the date of the recertification

Revised Certification

  • Revised CMN
  • Copy of most recent blood gas study prior to the revised certification date (if the estimated length of need on the Initial CMN was less than lifetime, this blood gas study must be performed within 30 days prior to the revised date)

Portable Oxygen Systems

Medical records that support:

  • the patient is mobile within the home; and
  • the qualifying blood gas study was performed at rest (awake) or during exercise.

Liter Flow Greater than 4 LPM

  • A copy of a blood gas study showing blood gas levels in the group I or II range while the patient was receiving oxygen at the rate of 4 LPM
Oxygen and Oxygen Equipment
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