If basic oxygen coverage criteria have been met, a higher allowance for a stationary system for a flow rate greater than four LPM will be paid if coverage criteria outlined in the LCD for oxygen and oxygen equipment are met.
Suppliers are reminded that the appropriate modifier must be used if the prescribed flow rate is greater than four LPM. These modifiers may be used only with stationary gaseous (E0424) or liquid (E0439) systems or with an oxygen concentrator (E1390, E1391). They may not be used with codes for portable systems or oxygen contents.
If coverage criteria are met, a portable oxygen system is usually payable separately in addition to the stationary system. However, if the prescribed oxygen amount is greater than four LPM, portable oxygen is not separately payable; payment for the portable equipment is included in the higher allowance for the stationary equipment.
If a Certificate of Medical Necessity CMS-484 is submitted to the DME MAC and question five indicates the flow rate ordered for the patient is greater than four LPM and question six is answered and includes Group I or Group II qualifying test results that support the medical need for greater than four LPM, either the QF or QG modifier must be appended to the HCPCS code for the stationary liquid or gaseous systems (E0424, E0439) or concentrator (E1390–E1391). If the QF or QG modifiers are omitted, the claim will be rejected with ANSI code CO-4, which states “procedure code is inconsistent with the modifier used, or a required modifier is missing.”
If question five indicates the flow rate ordered for the patient is greater than four LPM and question six is not answered or does not support the medical need for greater than four LPM, the QF or QG modifiers should not be appended. The claim will pay or deny accordingly.
If question six is answered and the test result reported meets Group II coverage criteria (i.e., PO 2 at 56–59 mm Hg or oxygen saturation = 89 percent), question seven–nine must also be answered to indicate the patient has a qualifying condition, as required by the LCD. If the patient does not have at least one qualifying condition (i.e., questions seven–nine are all answered no), or are not answered, Group II coverage has not been met, and the QF or QG modifiers should not be appended. The claim will pay or deny accordingly.
Furthermore, if an oxygen claim is submitted with a Certificate of Medical Necessity CMS-484 and question five indicates a flow rate less than 4 LPM, the QF or QG modifier must not be appended to the HCPCS code for the stationary liquid or gaseous systems (E0424, E0439) or concentrator (E1390–E1391); otherwise the claim will be rejected with ANSI code CO-4, “procedure code is inconsistent with the modifier used, or a required modifier is missing.”
If a Certificate of Medical Necessity CMS-484 is submitted to the DME MAC and question five indicates the flow rate ordered for the patient is less than one LPM, the QE modifier must be appended to the HCPCS code for the stationary liquid or gaseous systems (E0424, E0439) or concentrator (E1390–E1391). If the QE modifier is omitted, the claim will be rejected with ANSI CO-4, which states “procedure code is inconsistent with the modifier used, or a required modifier is missing.”
Furthermore, if an oxygen claim is submitted with a CMS-484 CMN and question five indicates a flow rate greater than one LPM and the QE modifier is appended, the claim will be rejected with ANSI code CO-4 for incorrect coding.
Additional information related to oxygen and oxygen equipment can be found in the oxygen and oxygen equipment local coverage determination and policy article.
