Showing posts with label modifier. Show all posts
Showing posts with label modifier. Show all posts
Specific Modifiers for Distinct Procedural Services
New coding requirements related to Healthcare Common Procedure Coding System (HCPCS) modifier -59 could impact your reimbursement.
Change Request (CR) 8863 notifies MACs and providers that the Centers for Medicare and Medicaid Services (CMS) is establishing four new HCPCS modifiers to define subsets of the - 59 modifier, a modifier used to define a "Distinct Procedural Service"
The Medicare National Correct Coding Initiative (NCCI) has Procedure to Procedure (PTP) edits to prevent unbundling of services, and the consequent overpayment to physicians and outpatient facilities. The underlying principle is that the second code defines a subset of the work of the first code. Reporting the codes separately is inappropriate. Separate reporting would trigger a separate payment and would constitute double billing.
CR 8863 discusses changes to HCPCS modifier- 59, a modifier which is used to define a "Distinct Procedural Service." Modifier - 59 indicates that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled.
The 59 modifier is the most widely used HCPCS modifier. Modifier -59 can be broadly applied. Some providers incorrectly consider it to be the "modifier to use to bypass (NCCI)." This modifier is associated abuse and high levels of manual audit activity; leading to reviews, appeals and even civil fraud and abuse cases.
The primary issue associated with the 59 modifier is that it is defined for use in a wide variety of circumstances, such as to identify:
• Different encounters;
• Different anatomic sites; and
• Distinct services.
The 59 modifier is
• Infrequently (and usually correctly) used to identify a separate encounter;
• Less commonly (and less correctly)used to define a separate anatomic site; and
• More commonly (and frequently incorrectly) used to define a distinct service.
The 59 modifier often overrides the edit in the exact circumstance for which CMS created it in the first place.CMS believes that more precise coding options coupled with increased education and selective editing is needed to reduce the errors associated with this overpayment.
CR 8863 provides that CMS is establishing the following four new HCPCS modifiers (referred to collectively as - X{EPSU} modifiers) to define specific subsets of the 59 modifier:
XE Separate Encounter, A Service That Is Distinct Because IT Occurred During A Separate Encounter,
XS Separate Structure, A Service That Is Distinct Because It Was Performed on a Separate Organ/Structure,
XP Separate Practitioner, A Service That Is Distinct Because It was performed by a different practitioner, and
XU Unusual Non-Overlapping Service, The Use of a Service That Is Distinct Because It Does Not Overlap Usual Components Of the Main Service.
CMS will continue to recognize the 59 modifier, but notes that Current Procedural Terminology (CPT) instructions state that the 59 modifier should not be used when a more descriptive modifier is available. While CMS will continue to recognize the 59 modifier in many instances, it may selectively require a more specific - X {EPSU} modifier for billing certain codes at high risk for incorrect billing. For example, a particular NCCI PTP code pair may be identified as payable only with the - XE separate encounter modifier but not the 59 or other - X {EPSU} modifiers. The - X {EPSU} modifiers are more selective versions of the 59 modifier so it would be incorrect to include both modifiers on the same line.
The combination of alternative specific modifiers with a general less specific modifier creates additional discrimination in both reporting and editing. As a default, at this time CMS will initially accept either a 59 modifier or a more selective - X {EPSU} modifier as correct coding, although the rapid migration of providers to the more selective modifiers is encouraged.
However, please note that these modifiers are valid even before national edits are in place. MACs are not prohibited from requiring the use of selective modifiers in lieu of the general 59 modifier, when necessitated by local program integrity and compliance needs.
CLAIM INSTRUCTIONS WHEN A VALID ABN IS ON FILE - Modifier usage
When the previous instructions have been followed and a valid ABN on file, the following modifiers should be used to notify Medicare:
- GA Use to indicate that an ABN was given as required by payer policy. A copy of the ABN does not have to be submitted but must be made available upon request.
- GX Used to indicate that an ABN was given voluntarily under payer policy (UB-04) claims.
- GZ Use when an item or service is expected to be denied as not reasonable and necessary and an ABN has not been signed. Effective July 1, 2011, all claim line items submitted with a GZ modifier will be denied automatically and will not be subject to complex medical review.
Upgrade modifiers and resubmit the claim
Resubmitting Claims with Upgrade Modifiers - Effective 02/04/2011
Recently the Durable Medical Equipment Medicare Administrative Contractors (DME MAC) issued bulletin articles regarding the use of upgrade modifiers in conjunction with HCPCS codes subject to the elimination of least costly alternative (LCA). For certain items that were previously subject to LCA, suppliers will now receive a not reasonable and necessary denial. The article indicated that further instructions would be forthcoming concerning the options that a supplier has if a claim for an item previously subject to LCA is submitted without upgrade modifiers, is subsequently denied as not reasonable and necessary and the supplier decides that it would like to utilize the upgrade modifiers.
For items that were previously subject to LCA, suppliers have the option of resubmitting the claim using the upgrade modifiers and the code for the covered medically necessary item rather than exercising the option of Appeals. For example, a supplier submits a claim after February 04, 2011 for code E0265 (fully electric hospital bed) and the claim is denied as not reasonable and necessary. That claim may be resubmitted with code E0265 and the appropriate modifiers on Line 1 and code E0260 and the appropriate modifiers on Line 2. Resubmitting the claim in this fashion will not result in a conflict with the original code E0265 claim and subsequent duplicate claim denial.
These resubmission instructions apply only to items previously subject to LCA payment policy that now receive not reasonable and necessary denials. Other items receiving reasonable and necessary denials must follow the usual redeterminations process.
Recently the Durable Medical Equipment Medicare Administrative Contractors (DME MAC) issued bulletin articles regarding the use of upgrade modifiers in conjunction with HCPCS codes subject to the elimination of least costly alternative (LCA). For certain items that were previously subject to LCA, suppliers will now receive a not reasonable and necessary denial. The article indicated that further instructions would be forthcoming concerning the options that a supplier has if a claim for an item previously subject to LCA is submitted without upgrade modifiers, is subsequently denied as not reasonable and necessary and the supplier decides that it would like to utilize the upgrade modifiers.
For items that were previously subject to LCA, suppliers have the option of resubmitting the claim using the upgrade modifiers and the code for the covered medically necessary item rather than exercising the option of Appeals. For example, a supplier submits a claim after February 04, 2011 for code E0265 (fully electric hospital bed) and the claim is denied as not reasonable and necessary. That claim may be resubmitted with code E0265 and the appropriate modifiers on Line 1 and code E0260 and the appropriate modifiers on Line 2. Resubmitting the claim in this fashion will not result in a conflict with the original code E0265 claim and subsequent duplicate claim denial.
These resubmission instructions apply only to items previously subject to LCA payment policy that now receive not reasonable and necessary denials. Other items receiving reasonable and necessary denials must follow the usual redeterminations process.
Medicare oxygen equipement - CPT code - service coverage
HCPCS CODES:
EQUIPMENT:
Group 1 Codes:
E0424 STATIONARY COMPRESSED GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES CONTAINER, CONTENTS, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND TUBING
E0425 STATIONARY COMPRESSED GAS SYSTEM, PURCHASE; INCLUDES REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND TUBING
E0430 PORTABLE GASEOUS OXYGEN SYSTEM, PURCHASE; INCLUDES REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASK, AND TUBING
E0431 PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE CONTAINER, REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASK, AND TUBING
E0433 PORTABLE LIQUID OXYGEN SYSTEM, RENTAL; HOME LIQUEFIER USED TO FILL PORTABLE LIQUID OXYGEN CONTAINERS, INCLUDES PORTABLE CONTAINERS, REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASK AND TUBING, WITH OR WITHOUT SUPPLY RESERVOIR AND CONTENTS GAUGE
E0434 PORTABLE LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE CONTAINER, SUPPLY RESERVOIR, HUMIDIFIER, FLOWMETER, REFILL ADAPTOR, CONTENTS GAUGE, CANNULA OR MASK, AND TUBING
E0435 PORTABLE LIQUID OXYGEN SYSTEM, PURCHASE; INCLUDES PORTABLE CONTAINER, SUPPLY RESERVOIR, FLOWMETER, HUMIDIFIER, CONTENTS GAUGE, CANNULA OR MASK, TUBING AND REFILL ADAPTOR
E0439 STATIONARY LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES CONTAINER, CONTENTS, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, & TUBING
E0440 STATIONARY LIQUID OXYGEN SYSTEM, PURCHASE; INCLUDES USE OF RESERVOIR, CONTENTS INDICATOR, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND TUBING
E0441 STATIONARY OXYGEN CONTENTS, GASEOUS, 1 MONTH'S SUPPLY = 1 UNIT
E0442 STATIONARY OXYGEN CONTENTS, LIQUID, 1 MONTH'S SUPPLY = 1 UNIT
E0443 PORTABLE OXYGEN CONTENTS, GASEOUS, 1 MONTH'S SUPPLY = 1 UNIT
E0444 PORTABLE OXYGEN CONTENTS, LIQUID, 1 MONTH'S SUPPLY = 1 UNIT
E0445 OXIMETER DEVICE FOR MEASURING BLOOD OXYGEN LEVELS NON-INVASIVELY
E0446 TOPICAL OXYGEN DELIVERY SYSTEM, NOT OTHERWISE SPECIFIED, INCLUDES ALL SUPPLIES AND ACCESSORIES
E1390 OXYGEN CONCENTRATOR, SINGLE DELIVERY PORT, CAPABLE OF DELIVERING 85 PERCENT OR GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE
E1391 OXYGEN CONCENTRATOR, DUAL DELIVERY PORT, CAPABLE OF DELIVERING 85 PERCENT OR GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE, EACH
E1392 PORTABLE OXYGEN CONCENTRATOR, RENTAL
E1405 OXYGEN AND WATER VAPOR ENRICHING SYSTEM WITH HEATED DELIVERY
E1406 OXYGEN AND WATER VAPOR ENRICHING SYSTEM WITHOUT HEATED DELIVERY
K0738 PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; HOME COMPRESSOR USED TO FILL PORTABLE OXYGEN CYLINDERS; INCLUDES PORTABLE CONTAINERS, REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASK, AND TUBING
Group 2 Paragraph: ACCESSORIES:
Group 2 Codes:
A4575 TOPICAL HYPERBARIC OXYGEN CHAMBER, DISPOSABLE
A4606 OXYGEN PROBE FOR USE WITH OXIMETER DEVICE, REPLACEMENT
A4608 TRANSTRACHEAL OXYGEN CATHETER, EACH
A4615 CANNULA, NASAL
A4616 TUBING (OXYGEN), PER FOOT
A4617 MOUTH PIECE
A4619 FACE TENT
A4620 VARIABLE CONCENTRATION MASK
A7525 TRACHEOSTOMY MASK, EACH
A9900 MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE
E0455 OXYGEN TENT, EXCLUDING CROUP OR PEDIATRIC TENTS
E0555 HUMIDIFIER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC BOTTLE TYPE, FOR USE WITH REGULATOR OR FLOWMETER
E0580 NEBULIZER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC, BOTTLE TYPE, FOR USE WITH REGULATOR OR FLOWMETER
E1352 OXYGEN ACCESSORY, FLOW REGULATOR CAPABLE OF POSITIVE INSPIRATORY PRESSURE
E1353 REGULATOR
E1354 OXYGEN ACCESSORY, WHEELED CART FOR PORTABLE CYLINDER OR PORTABLE CONCENTRATOR, ANY TYPE, REPLACEMENT ONLY, EACH
E1355 STAND/RACK
E1356 OXYGEN ACCESSORY, BATTERY PACK/CARTRIDGE FOR PORTABLE CONCENTRATOR, ANY TYPE, REPLACEMENT ONLY, EACH
E1357 OXYGEN ACCESSORY, BATTERY CHARGER FOR PORTABLE CONCENTRATOR, ANY TYPE, REPLACEMENT ONLY, EACH
E1358 OXYGEN ACCESSORY, DC POWER ADAPTER FOR PORTABLE CONCENTRATOR, ANY TYPE, REPLACEMENT ONLY, EACH
Oxygen and Oxygen Equipment
For stationary and portable oxygen equipment furnished on or after January 1, 2006, a 36-month cap applies on monthly payments. A listing of the applicable HCPCS codes is available in Chapter 5 of the Supplier Manual.
For stationary and portable oxygen equipment and oxygen contents furnished prior to January 1, 2006, payments were made for the duration of use of the equipment when medically necessary.
Contractors began the 36-month count on January 1, 2006, for beneficiaries that were receiving oxygen therapy prior to January 1, 2006. Months prior to January 1, 2006, are not included in the 36-month count.
On the first day after the 36th month anniversary for which payment has been made, the supplier must transfer the title for the stationary and/or portable oxygen equipment to the beneficiary. On that same day, the title for the equipment is transferred to the patient and monthly payments can begin to be made for oxygen contents used with patient owned gaseous and liquid oxygen equipment.
Modifiers appropriate for oxygen and oxygen equipment are:
• RR Rental
• QE Use if the prescribed amount of oxygen is less than 1 LPM
• QF Use if the prescribed amount of oxygen exceeds 4 LPM and portable oxygen is prescribed
• QG Use if the prescribed amount of oxygen is greater than 4 LPM
• QH Use if an oxygen conserving device is being used with an oxygen delivery system
Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity
For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act §1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.
Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee For Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.
For an item to be covered by Medicare, a detailed written order (DWO) must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as not reasonable and necessary.
For some items in this policy to be covered by Medicare, a written order prior to delivery (WOPD) is required. Refer to the DOCUMENTATION REQUIREMENTS section of this LCD and to the NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section of the related Policy Article for information about WOPD prescription requirements
Home oxygen is covered only when both the reasonable and necessary criteria discussed below and the statutory criteria discussed in the Policy Article are met. Refer to the Policy Article for additional information on statutory payment policy requirements.
Home oxygen therapy is reasonable and necessary only if all of the following conditions are met:
The treating physician 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 criteria stated below, and
The qualifying blood gas study was performed by a physician or by a qualified provider or supplier of laboratory services, and
The qualifying blood gas study was obtained under the following conditions:
If the qualifying blood gas study is performed during an inpatient hospital stay, the reported test must be the one obtained closest to, but no earlier than 2 days prior to the hospital discharge date, or
If the qualifying blood gas study is not performed during an inpatient hospital stay, the reported test must be performed while the beneficiary is in a chronic stable state – i.e., not during a period of acute illness or an exacerbation of their underlying disease, and
Alternative treatment measures have been tried or considered and deemed clinically ineffective.
In this policy, the term blood gas study refers to either an oximetry test or an arterial blood gas test.
Group I criteria include any of the following:
An arterial PO 2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent taken at rest (awake), or
An arterial PO 2 at or below 55 mm Hg, or an arterial oxygen saturation at or below 88 percent, for at least 5 minutes taken during sleep for a beneficiary who demonstrates an arterial PO 2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89 percent while awake, or
A decrease in arterial PO 2 more than 10 mm Hg, or a decrease in arterial oxygen saturation more than 5 percent from baseline saturation, for at least 5 minutes taken during sleep associated with symptoms (e.g., impairment of cognitive processes and [nocturnal restlessness or insomnia]) or signs (e.g., cor pulmonale, "P" pulmonale on EKG, documented pulmonary hypertension and erythrocytosis) reasonably attributable to hypoxemia, or
An arterial PO 2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent, taken during exercise for a beneficiary who demonstrates an arterial PO 2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89 percent during the day while at rest. In this case, oxygen is provided for during exercise if it is documented that the use of oxygen improves the hypoxemia that was demonstrated during exercise when the beneficiary was breathing room air.
Initial coverage for beneficiaries meeting Group I criteria is limited to 12 months or the physician-specified length of need, whichever is shorter. (Refer to the Certification section for information on recertification.)
Group II criteria include the presence of
An arterial PO 2 of 56-59 mm Hg or an arterial blood oxygen saturation of 89 percent at rest (awake), during sleep for at least 5 minutes, or during exercise (as described under Group I criteria), and
Any of the following:
Dependent edema suggesting congestive heart failure, or
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
Erythrocythemia with a hematocrit greater than 56 percent.
Initial coverage for beneficiaries meeting Group II criteria is limited to 3 months or the physician specified length of need, whichever is shorter. (Refer to the Certification section for information on recertification.) Group III includes beneficiaries with arterial PO 2 levels at or above 60 mm Hg or arterial blood oxygen saturations at or above 90 percent. For these beneficiaries there is a rebuttable presumption of non-coverage.
If all of the coverage conditions specified above are not met, the oxygen therapy will be denied as not reasonable and necessary. Oxygen therapy will also be denied as not reasonable and necessary if any of the following conditions are present:
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.
Dyspnea without cor pulmonale or evidence of hypoxemia
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 PO 2 will improve the oxygenation of tissues with impaired circulation.
Terminal illnesses that do not affect the respiratory system
LONG TERM OXYGEN THERAPY CLINICAL (LTOT) TRIALS
Oxygen and oxygen equipment is covered for beneficiaries who are enrolled subjects in clinical trials approved by CMS and sponsored by the National Heart, Lung, and Blood Institute (NHLBI) and who have an arterial PO 2 from 56 to 65 mm Hg or an oxygen saturation at or above 89 percent. The additional Group 2 coverage criteria do not apply to these beneficiaries.
Refer to the APPENDICES section of this policy for additional information about approved clinical trials.
CLUSTER HEADACHES (CH):
Only a stationary gaseous oxygen system (E0424) and related contents (E0441) are covered for the treatment of cluster headaches for beneficiaries enrolled in a clinical trial approved by CMS which are in compliance with the requirements described in the CMS National Coverage Determination Manual (Internet Only Manual 100-03) §240.2.2 for dates of service on or after 01/04/2011. This section states, in part:
Only those beneficiaries diagnosed with the condition of cluster headache are eligible for participation in a clinical study. CMS adopts the diagnostic criteria used by the International Headache Society to form a definitive diagnosis of CH. Therefore, the home use of oxygen to treat CH is covered by Medicare only when furnished to Medicare beneficiaries who have had at least five severe to very severe unilateral headache attacks lasting 15-180 minutes when untreated. (Intensity of pain: Degree of pain usually expressed in terms of its functional consequence and scored on a verbal 5-point scale: 0=no pain; 1=mild pain, does not interfere with usual activities; 2=moderate pain, inhibits but does not wholly prevent usual activities; 3=severe pain, prevents all activities; 4=very severe pain. It may also be expressed on a visual analogue scale.)
The headaches must be accompanied by at least one of the following findings:
Ipsilateral conjunctival injection and/or lacrimation; or
Ipsilateral nasal congestion and/or rhinorrhea; or
Ipsilateral eyelid edema; or
Ipsilateral forehead and facial sweating; or
Ipsilateral miosis and/or ptosis; or
A sense of restlessness or agitation
Claims for oxygen equipment not meeting the criteria above will be denied as not reasonable and necessary.
Claims for stationary oxygen equipment other than E0424 and all portable oxygen equipment used for cluster headaches will be denied as not reasonable and necessary.
Claims for E0424 and E0441 used to treat cluster headaches follow the same payment rules for all other covered oxygen equipment. Refer to the related Policy Article for information on statutory payment rules and coding guidelines to be used for these claims.
Refer to the APPENDICES section of this policy for additional information about approved clinical trials.
Reference Diagnosis Codes that Support Medical Necessity section for applicable diagnoses.
TESTING SPECIFICATIONS:
General
For purposes of this policy:
“Blood gas study” shall refer to both arterial blood gas (ABG) studies and pulse oximetry
“Oximetry” shall refer to routine or “spot” pulse oximetry
“Overnight oximetry” shall refer to 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.
Refer to the Positive Airway Pressure Devises used for the Treatment of Obstructive Sleep Apnea policy for information on sleep tests used for the diagnosis of sleep apnea.
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. This includes a requirement that the test be performed by a provider who is qualified to bill Medicare for the test – i.e., a Part A provider, a laboratory, an Independent Diagnostic Testing Facility (IDTF), or a physician. A supplier is not considered a qualified provider or a qualified laboratory for purposes of this policy. Blood gas studies performed by a supplier are not acceptable. In addition, the qualifying blood gas study may not be paid for by any supplier. These prohibitions do not extend to blood gas studies performed by a hospital certified to do such tests.
The qualifying blood gas study may be performed while the beneficiary is on oxygen as long as the reported blood gas values meet the Group I or Group II criteria.
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. If an ABG test done at rest and awake is non-qualifying, but either an exercise or sleep oximetry test on the same day is qualifying, the exercise or oximetry test result will determine coverage.
All oxygen qualification testing must be performed in-person by a physician or other medical professional qualified to conduct oximetry testing. With the exception of overnight oximetry (see below), unsupervised or remotely supervised home testing does not qualify as a valid test for purposes of Medicare reimbursement of home oxygen and oxygen equipment.
Exercise testing
When oxygen is covered based on an oximetry study obtained during exercise, there must be documentation of three (3) oximetry studies in the beneficiary’s medical record. (1) Testing at rest without oxygen, (2) testing during exercise without oxygen, and (3) testing during exercise with oxygen applied (to demonstrate the improvement of the hypoxemia) are required. All 3 tests must be performed within the same testing session. Exercise testing must be performed in-person by a physician or other medical professional qualified to conduct exercise oximetry testing. Unsupervised or remotely supervised home exercise testing does not qualify as a valid test for purposes of Medicare reimbursement of home oxygen and oxygen equipment. Only the testing during exercise without oxygen is used for qualification and reported on the CMN. The other two results do not have to be routinely submitted but must be available on request.
Oximetry obtained after exercise while resting, sometimes referred to as “recovery” testing, is not part of the three required test elements and is not valid for determining eligibility for oxygen coverage.
Overnight Oximetry Studies:
Overnight sleep oximetry may be performed in a facility or at home. For home overnight oximetry studies, the oximeter provided to the beneficiary must be tamper-proof and must have the capability to download data that allows documentation of the duration of oxygen desaturation below a specified value.
For all the overnight oximetry criteria described above, the 5 minutes does not have to be continuous. Baseline saturation is defined as the mean saturation level during the duration of the test. For purposes of meeting criterion 3 described in Group I above there must be a minimum of 2 hours test time recorded for sleep oximetry. The result must reach a qualifying test value otherwise the Group III presumption of non-coverage applies.
Home overnight oximetry is limited solely to stand-alone overnight pulse oximetry performed in the beneficiary’s home under the conditions specified below. Overnight oximetry performed as part of home sleep testing or as part of any other home testing is not considered to be eligible under this provision to be used for qualification for reimbursement of home oxygen and oxygen equipment even if the testing was performed in compliance with the requirements of this section.
Beneficiaries may self-administer home based overnight oximetry tests under the direction of a Medicare-enrolled Independent Diagnostic Testing Facility (IDTF). A DME supplier or another shipping entity may deliver a pulse oximetry test unit and related technology to a beneficiary’s home under the following circumstances:
The beneficiary’s treating physician has contacted the IDTF to order an overnight pulse oximetry test before the test is performed.
The test is performed under the direction and/or instruction of a Medicare-approved IDTF. Because it is the beneficiary who self-administers this test, the IDTF must provide clear written instructions to the beneficiary on proper operation of the test equipment and must include access to the IDTF in order to address other concerns that may arise. The DME supplier may not create this written instruction, provide verbal instructions, answer questions from the beneficiary, apply or demonstrate the application of the testing equipment to the beneficiary, or otherwise participate in the conduct of the test.
The test unit is sealed and tamper-proof such that test results cannot be accessed by anyone other than the IDTF which is responsible for transmitting a test report to the treating physician. The DME supplier may use related technology to download test results from the testing unit and transmit those results to the IDTF. In no case may the DME supplier access or manipulate the test results in any form.
The IDTF must send the test results to the physician. The IDTF may send the test results to the supplier if the supplier is currently providing or has an order to provide oxygen or other respiratory services to the beneficiary or if the beneficiary has signed a release permitting the supplier to receive the report.
Oximetry test results obtained through a similar process as described for home overnight oximetry (see above) while the beneficiary is awake, either at rest or with exercise, may not be used for purposes of qualifying the beneficiary for home oxygen therapy.
Overnight oximetry does not include oximetry obtained during polysomnography or other sleep testing for sleep apnea, regardless of the location the testing was performed. See below for information on sleep testing that may be used to qualify for oxygen coverage.
Obstructive Sleep Apnea (OSA), Polysomnography and Home Sleep Tests:
Some beneficiaries may require the simultaneous use of home oxygen therapy with a PAP device. To be considered for simultaneous coverage, all requirements in the Coverage Indications, Limitations and/or Medical Necessity for both the Oxygen and Oxygen Equipment and Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea LCDs must be met. Consequently, in addition to this Oxygen LCD, suppliers should refer to the Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea LCD and related Policy Article for additional coverage, coding and documentation requirements.
Coverage of home oxygen therapy requires that the beneficiary be tested in the “chronic stable state.” Chronic stable state is a requirement of the National Coverage Determination (CMS Internet-only Manual, Pub. 100-03, Section 240.2) and is one of the key criteria when determining coverage of home oxygen therapy. The NCD defines chronic stable state as “…not during a period of an acute illness or an exacerbation of their underlying disease.” Based on this NCD definition, all co-existing diseases or conditions that can cause hypoxia must be treated and the beneficiary must be in a chronic stable state before oxygen therapy is considered eligible for payment. In addition, the beneficiary must have a severe lung disease, such as chronic obstructive pulmonary disease, diffuse interstitial lung disease, cystic fibrosis, bronchiectasis, widespread pulmonary neoplasm, or hypoxia-related symptoms or findings that might be expected to improve with oxygen therapy. In the case of OSA, it is required that the OSA be appropriately and sufficiently treated such that the beneficiary is in the chronic stable state before oxygen saturation results obtained during sleep testing are considered qualifying for oxygen therapy (see PAP LCD for additional information).
For beneficiaries with OSA, this means that the OSA must be sufficiently treated such that the underlying severe lung disease is unmasked. This must be demonstrated before oxygen saturation results obtained during polysomnography are considered qualifying for oxygen therapy.
For beneficiaries 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:
The titration is conducted over a minimum of two (2) hours; and
During titration:
The AHI/RDI is reduced to less than or equal to an average of ten (10) events per hour; or
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
Nocturnal oximetry conducted for the purpose for oxygen reimbursement qualification may only be performed after optimal PAP settings have been determined and the beneficiary is using the PAP device at those settings; and
The nocturnal oximetry conducted during the PSG demonstrates an oxygen saturation = 88% for 5 minutes total (which need not be continuous)
If all of the above criteria are met, for the purposes of a qualifying oxygen saturation test, the beneficiary is considered to be in the “chronic stable state.” To be eligible for Medicare coverage and payment for home oxygen therapy for concurrent use with PAP therapy, in addition to being in the chronic stable state, the beneficiary must meet all other coverage requirements for oxygen therapy. Beneficiaries that qualify for oxygen therapy based on testing conducted only during the course of a sleep test are eligible only for reimbursement of stationary equipment.
Overnight oximetry performed as part of home sleep testing or as part of any other home testing is not considered as eligible to be used for qualification for reimbursement of home oxygen and oxygen equipment (see overnight oximetry section above for additional information).
Claims for oxygen equipment and supplies for beneficiaries who do not meet the coverage requirements for home oxygen therapy will be denied as not reasonable and necessary.
CERTIFICATION:
An Initial, Recertification, or Revised CMN must be obtained and submitted in the situations described below. The Initial Date, Recertification Date, and Revised Date specified below refer to the dates reported in Section A of the CMN.
Initial CMN is required:
With the first claim for home oxygen, (even if the beneficiary was on oxygen prior to Medicare eligibility or oxygen was initially covered by a Medicare HMO).
During the first 36 months of the rental period, when there has been a change in the beneficiary’s condition that has caused a break in medical necessity of at least 60 days plus whatever days remain in the rental month during which the need for oxygen ended. Refer to the Policy Article NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES for additional information.
When the equipment is replaced because the reasonable useful lifetime of prior equipment has been reached.
When the equipment is replaced because of irreparable damage, theft, or loss of the originally dispensed equipment.
Irreparable damage refers to a specific accident or to a natural disaster [e.g., fire, flood]
Irreparable damage does not refer to wear and tear over time
Testing and Visit Requirements:
Initial CMN for situations 1 and 2
The blood gas study must be the most recent study obtained within 30 days prior to the Initial Date.
For situation 1, there is an exception to the 30-day test requirement for beneficiaries who were started on oxygen while enrolled in a Medicare HMO and transition to fee-for-service Medicare. For those beneficiaries, the blood gas study does not have to be obtained 30 days prior to the Initial Date, but must be the most recent qualifying test obtained while in the HMO.
The beneficiary must be seen and evaluated by the treating physician within 30 days prior to the date of Initial Certification.
Initial CMN for scenarios 3 and 4 (replacement equipment)
Repeat blood gas testing is not required. Enter the most recent qualifying value and test date. This test does not have to be within 30 days prior to the Initial Date. It could be the test result reported on the most recent prior CMN.
There is no requirement for a physician visit that is specifically related to the completion of the CMN for replacement equipment.
Recertification CMN is required:
12 months after Initial Certification, (i.e., with the thirteenth month’s claim) for Group I
3 months after Initial Certification, (i.e., with the fourth month’s claim) for Group II
Testing and Visit Requirements:
Recertification following initial certification situations 1 and 2
For beneficiaries initially meeting Group I criteria, the most recent qualifying blood gas study prior to the thirteenth month of therapy must be reported on the Recertification CMN.
For beneficiaries initially meeting Group II criteria, the most recent blood gas study that was performed between the 61st and 90th day following Initial Certification must be reported on the Recertification CMN. If a qualifying test is not obtained between the 61st and 90th day of home oxygen therapy but the beneficiary continues to use oxygen and a test is obtained at a later date, if that test meets Group I or II criteria, coverage would resume beginning with the date of that test.
For beneficiaries initially meeting group I or II criteria, the beneficiary must be seen and re-evaluated by the treating physician within 90 days prior to the date of any Recertification. If the physician visit is not obtained within the 90-day window but the beneficiary continues to use oxygen and the visit is obtained at a later date, coverage would resume beginning with the date of that visit.
Recertification following initial situations 3 and 4 (replacement equipment)
Repeat testing is not required. Enter the most recent qualifying value and test date. This test does not have to be within 30 days prior to the Initial Date. It could be the test result reported on the most recent prior CMN.
There is no requirement for a physician visit that is specifically related to the completion of the CMN for replacement equipment.
Revised CMN is required:
When the prescribed maximum flow rate changes from one of the following categories to another:
Less than 1 LPM,
1-4 LPM,
Greater than 4 LPM
If the change is from category (a) or (b) to category (c), a repeat blood gas study with the beneficiary on 4 LPM must be performed.
When the length of need expires – if the physician specified less than lifetime length of need on the most recent CMN
When a portable oxygen system is added subsequent to Initial Certification of a stationary system
When a stationary system is added subsequent to Initial Certification of a portable system
When there is a new treating physician but the oxygen order is the same
If there is a new supplier and that supplier does not have the prior CMN
Submission of a Revised CMN does not change the Recertification schedule specified above.
If the indications for a Revised CMN are met at the same time that a Recertification CMN is due, file the CMN as a Recertification CMN.
Testing and Visit Requirements:
None of the Revised Certification situations (7-12) require a physician visit.
Revised Certification situations 7 and 8
The blood gas study must be the most recent study obtained within 30 days prior to the Initial Date.
Revised Certification situation 9
There is no requirement for a repeat blood gas study unless the initial qualifying study was performed during sleep, in which case a repeat blood gas study must be performed while the beneficiary is at rest (awake) or during exercise within 30 days prior to the Revised Date.
Revised Certifications situations 10-12
No blood gas study is required
For situations 11 and 12, the revised certification does NOT have to be submitted with the claim.
General:
Beneficiaries do not change group classification going from an initial certification to a recertification based upon changes in blood oxygen testing results. For example: A beneficiary initially qualifies for group II with an 89% oximetry value. At the 3-month retest a result of 87% is obtained. Despite the group I retesting value, the beneficiary remains in group II. There is no reclassification to group I. Further recertification is not required unless:
A non-qualifying test result is obtained at the time of recertification but the beneficiary later obtains a qualifying test result; or,
The specified length of need (LON) is reached.
Generally only one recertification is required regardless of group classification unless the LON specified on the recertification CMN is some value other than 99 (indicating lifetime). If other than lifetime is specified the certification will expire when the specified LON time period elapses. A recertification will be required to continue coverage.
Recertification is required to be completed on or prior to the end of the initial certification period. If timely recertification is not completed by the end of the initial certification period, reimbursement ends until the recertification is completed. At such time that the recertification requirements are met, payment will resume at the month in the rental cycle where the rental was stopped due to the expiration of the initial certification. A new, initial rental cycle does not begin when the recertification requirements are met.
A completed and signed Certificate of Medical Necessity (CMN) is required to receive payment for oxygen. Claims submitted without a valid CMN will be denied as not reasonable and necessary.
PORTABLE OXYGEN SYSTEMS:
A portable oxygen system is covered if the beneficiary is mobile within the home 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 will be denied as not reasonable and necessary.
If coverage criteria are met, a portable oxygen system is usually separately payable in addition to the stationary system. See exception in the related Policy Article Non-Medical Necessity Coverage and Payment Rules, OXYGEN EQUIPMENT, Initial 36-Months section.
If a portable oxygen system is covered, the supplier must provide whatever quantity of oxygen the beneficiary uses; Medicare’s reimbursement is the same, regardless of the quantity of oxygen dispensed.
LITER FLOW GREATER THAN 4 LPM:
If basic oxygen coverage criteria have been met, a higher allowance for a stationary system for a flow rate of greater than 4 liters per minute (LPM) will be paid only if a blood gas study performed while the beneficiary is on 4 or more LPM meets Group I or II criteria. If a flow rate greater than 4 LPM is billed and the coverage criterion for the higher allowance is not met, payment will be limited to the standard fee schedule allowance. (Refer to related Policy Article for additional information on payment for greater than 4 LPM oxygen.)
MISCELLANEOUS:
Oxygen reimbursement is a bundled payment. All options, supplies and accessories are considered included in the monthly rental payment for oxygen equipment. Oxygen rental is billed using the appropriate code for the provided oxygen equipment. Separately billed options, accessories or supply items will be denied as unbundling.
Emergency or stand-by oxygen systems for beneficiaries who are not regularly using oxygen will be denied as not reasonable and necessary since they are precautionary and not therapeutic in nature.
Topical hyperbaric oxygen chambers (A4575) will be denied as not reasonable and necessary. (IOM 100-03 20.29(B) & (C))
Topical oxygen delivery systems (E0446) will be denied as not reasonable and necessary. (IOM 100-03 20.29(C))
REFILLS OF OXYGEN CONTENTS:
For Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items and supplies provided on a recurring basis, billing must be based on prospective, not retrospective use.
Oxygen contents are reimbursed with a monthly allowance covering all contents necessary for the month. Supply allowances are not subject to the refill monitoring and documentation requirements specified by Medicare Program Integrity Manual section 5.2.6.
All other supplies, e.g. tubing, masks or cannulas, etc., are included in the monthly rental payment. Supplies that are not separately payable are not subject to the refill monitoring and documentation requirements specified by Medicare Program Integrity Manual section 5.2.6.
See the Non-Medical Coverage and Payment Rules section of the related Policy Article for additional information about coverage of oxygen contents.
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
N/A
Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
N/A
CPT/HCPCS Codes
Group 1 Paragraph: The appearance of a code in this section does not necessarily indicate coverage.
HCPCS MODIFIERS:
EY – No physician or other licensed health care provider order for this item or service
Q0 (Q-zero) - Investigational clinical service provided in a clinical research study that is in an approved clinical research study
QE - Prescribed amount of oxygen is less than 1 liter per minute (LPM)
QF - Prescribed amount of oxygen is greater than 4 liter per minute (LPM) and portable oxygen is prescribed
QG - Prescribed amount of oxygen is greater than 4 liters per minute (LPM)
QH - Oxygen conserving device is being used with an oxygen delivery system
EQUIPMENT:
Group 1 Codes:
E0424 STATIONARY COMPRESSED GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES CONTAINER, CONTENTS, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND TUBING
E0425 STATIONARY COMPRESSED GAS SYSTEM, PURCHASE; INCLUDES REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND TUBING
E0430 PORTABLE GASEOUS OXYGEN SYSTEM, PURCHASE; INCLUDES REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASK, AND TUBING
E0431 PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE CONTAINER, REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASK, AND TUBING
E0433 PORTABLE LIQUID OXYGEN SYSTEM, RENTAL; HOME LIQUEFIER USED TO FILL PORTABLE LIQUID OXYGEN CONTAINERS, INCLUDES PORTABLE CONTAINERS, REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASK AND TUBING, WITH OR WITHOUT SUPPLY RESERVOIR AND CONTENTS GAUGE
E0434 PORTABLE LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE CONTAINER, SUPPLY RESERVOIR, HUMIDIFIER, FLOWMETER, REFILL ADAPTOR, CONTENTS GAUGE, CANNULA OR MASK, AND TUBING
E0435 PORTABLE LIQUID OXYGEN SYSTEM, PURCHASE; INCLUDES PORTABLE CONTAINER, SUPPLY RESERVOIR, FLOWMETER, HUMIDIFIER, CONTENTS GAUGE, CANNULA OR MASK, TUBING AND REFILL ADAPTOR
E0439 STATIONARY LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES CONTAINER, CONTENTS, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, & TUBING
E0440 STATIONARY LIQUID OXYGEN SYSTEM, PURCHASE; INCLUDES USE OF RESERVOIR, CONTENTS INDICATOR, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND TUBING
E0441 STATIONARY OXYGEN CONTENTS, GASEOUS, 1 MONTH'S SUPPLY = 1 UNIT
E0442 STATIONARY OXYGEN CONTENTS, LIQUID, 1 MONTH'S SUPPLY = 1 UNIT
E0443 PORTABLE OXYGEN CONTENTS, GASEOUS, 1 MONTH'S SUPPLY = 1 UNIT
E0444 PORTABLE OXYGEN CONTENTS, LIQUID, 1 MONTH'S SUPPLY = 1 UNIT
E0445 OXIMETER DEVICE FOR MEASURING BLOOD OXYGEN LEVELS NON-INVASIVELY
E0446 TOPICAL OXYGEN DELIVERY SYSTEM, NOT OTHERWISE SPECIFIED, INCLUDES ALL SUPPLIES AND ACCESSORIES
E1390 OXYGEN CONCENTRATOR, SINGLE DELIVERY PORT, CAPABLE OF DELIVERING 85 PERCENT OR GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE
E1391 OXYGEN CONCENTRATOR, DUAL DELIVERY PORT, CAPABLE OF DELIVERING 85 PERCENT OR GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE, EACH
E1392 PORTABLE OXYGEN CONCENTRATOR, RENTAL
E1405 OXYGEN AND WATER VAPOR ENRICHING SYSTEM WITH HEATED DELIVERY
E1406 OXYGEN AND WATER VAPOR ENRICHING SYSTEM WITHOUT HEATED DELIVERY
K0738 PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; HOME COMPRESSOR USED TO FILL PORTABLE OXYGEN CYLINDERS; INCLUDES PORTABLE CONTAINERS, REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASK, AND TUBING
Group 2 Paragraph: ACCESSORIES:
Group 2 Codes:
A4575 TOPICAL HYPERBARIC OXYGEN CHAMBER, DISPOSABLE
A4606 OXYGEN PROBE FOR USE WITH OXIMETER DEVICE, REPLACEMENT
A4608 TRANSTRACHEAL OXYGEN CATHETER, EACH
A4615 CANNULA, NASAL
A4616 TUBING (OXYGEN), PER FOOT
A4617 MOUTH PIECE
A4619 FACE TENT
A4620 VARIABLE CONCENTRATION MASK
A7525 TRACHEOSTOMY MASK, EACH
A9900 MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE
E0455 OXYGEN TENT, EXCLUDING CROUP OR PEDIATRIC TENTS
E0555 HUMIDIFIER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC BOTTLE TYPE, FOR USE WITH REGULATOR OR FLOWMETER
E0580 NEBULIZER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC, BOTTLE TYPE, FOR USE WITH REGULATOR OR FLOWMETER
E1352 OXYGEN ACCESSORY, FLOW REGULATOR CAPABLE OF POSITIVE INSPIRATORY PRESSURE
E1353 REGULATOR
E1354 OXYGEN ACCESSORY, WHEELED CART FOR PORTABLE CYLINDER OR PORTABLE CONCENTRATOR, ANY TYPE, REPLACEMENT ONLY, EACH
E1355 STAND/RACK
E1356 OXYGEN ACCESSORY, BATTERY PACK/CARTRIDGE FOR PORTABLE CONCENTRATOR, ANY TYPE, REPLACEMENT ONLY, EACH
E1357 OXYGEN ACCESSORY, BATTERY CHARGER FOR PORTABLE CONCENTRATOR, ANY TYPE, REPLACEMENT ONLY, EACH
E1358 OXYGEN ACCESSORY, DC POWER ADAPTER FOR PORTABLE CONCENTRATOR, ANY TYPE, REPLACEMENT ONLY, EACH
Oxygen and Oxygen Equipment
For stationary and portable oxygen equipment furnished on or after January 1, 2006, a 36-month cap applies on monthly payments. A listing of the applicable HCPCS codes is available in Chapter 5 of the Supplier Manual.
For stationary and portable oxygen equipment and oxygen contents furnished prior to January 1, 2006, payments were made for the duration of use of the equipment when medically necessary.
Contractors began the 36-month count on January 1, 2006, for beneficiaries that were receiving oxygen therapy prior to January 1, 2006. Months prior to January 1, 2006, are not included in the 36-month count.
On the first day after the 36th month anniversary for which payment has been made, the supplier must transfer the title for the stationary and/or portable oxygen equipment to the beneficiary. On that same day, the title for the equipment is transferred to the patient and monthly payments can begin to be made for oxygen contents used with patient owned gaseous and liquid oxygen equipment.
Modifiers appropriate for oxygen and oxygen equipment are:
• RR Rental
• QE Use if the prescribed amount of oxygen is less than 1 LPM
• QF Use if the prescribed amount of oxygen exceeds 4 LPM and portable oxygen is prescribed
• QG Use if the prescribed amount of oxygen is greater than 4 LPM
• QH Use if an oxygen conserving device is being used with an oxygen delivery system
Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity
For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act §1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.
Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee For Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.
For an item to be covered by Medicare, a detailed written order (DWO) must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as not reasonable and necessary.
For some items in this policy to be covered by Medicare, a written order prior to delivery (WOPD) is required. Refer to the DOCUMENTATION REQUIREMENTS section of this LCD and to the NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section of the related Policy Article for information about WOPD prescription requirements
Home oxygen is covered only when both the reasonable and necessary criteria discussed below and the statutory criteria discussed in the Policy Article are met. Refer to the Policy Article for additional information on statutory payment policy requirements.
Home oxygen therapy is reasonable and necessary only if all of the following conditions are met:
The treating physician 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 criteria stated below, and
The qualifying blood gas study was performed by a physician or by a qualified provider or supplier of laboratory services, and
The qualifying blood gas study was obtained under the following conditions:
If the qualifying blood gas study is performed during an inpatient hospital stay, the reported test must be the one obtained closest to, but no earlier than 2 days prior to the hospital discharge date, or
If the qualifying blood gas study is not performed during an inpatient hospital stay, the reported test must be performed while the beneficiary is in a chronic stable state – i.e., not during a period of acute illness or an exacerbation of their underlying disease, and
Alternative treatment measures have been tried or considered and deemed clinically ineffective.
In this policy, the term blood gas study refers to either an oximetry test or an arterial blood gas test.
Group I criteria include any of the following:
An arterial PO 2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent taken at rest (awake), or
An arterial PO 2 at or below 55 mm Hg, or an arterial oxygen saturation at or below 88 percent, for at least 5 minutes taken during sleep for a beneficiary who demonstrates an arterial PO 2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89 percent while awake, or
A decrease in arterial PO 2 more than 10 mm Hg, or a decrease in arterial oxygen saturation more than 5 percent from baseline saturation, for at least 5 minutes taken during sleep associated with symptoms (e.g., impairment of cognitive processes and [nocturnal restlessness or insomnia]) or signs (e.g., cor pulmonale, "P" pulmonale on EKG, documented pulmonary hypertension and erythrocytosis) reasonably attributable to hypoxemia, or
An arterial PO 2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent, taken during exercise for a beneficiary who demonstrates an arterial PO 2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89 percent during the day while at rest. In this case, oxygen is provided for during exercise if it is documented that the use of oxygen improves the hypoxemia that was demonstrated during exercise when the beneficiary was breathing room air.
Initial coverage for beneficiaries meeting Group I criteria is limited to 12 months or the physician-specified length of need, whichever is shorter. (Refer to the Certification section for information on recertification.)
Group II criteria include the presence of
An arterial PO 2 of 56-59 mm Hg or an arterial blood oxygen saturation of 89 percent at rest (awake), during sleep for at least 5 minutes, or during exercise (as described under Group I criteria), and
Any of the following:
Dependent edema suggesting congestive heart failure, or
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
Erythrocythemia with a hematocrit greater than 56 percent.
Initial coverage for beneficiaries meeting Group II criteria is limited to 3 months or the physician specified length of need, whichever is shorter. (Refer to the Certification section for information on recertification.) Group III includes beneficiaries with arterial PO 2 levels at or above 60 mm Hg or arterial blood oxygen saturations at or above 90 percent. For these beneficiaries there is a rebuttable presumption of non-coverage.
If all of the coverage conditions specified above are not met, the oxygen therapy will be denied as not reasonable and necessary. Oxygen therapy will also be denied as not reasonable and necessary if any of the following conditions are present:
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.
Dyspnea without cor pulmonale or evidence of hypoxemia
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 PO 2 will improve the oxygenation of tissues with impaired circulation.
Terminal illnesses that do not affect the respiratory system
LONG TERM OXYGEN THERAPY CLINICAL (LTOT) TRIALS
Oxygen and oxygen equipment is covered for beneficiaries who are enrolled subjects in clinical trials approved by CMS and sponsored by the National Heart, Lung, and Blood Institute (NHLBI) and who have an arterial PO 2 from 56 to 65 mm Hg or an oxygen saturation at or above 89 percent. The additional Group 2 coverage criteria do not apply to these beneficiaries.
Refer to the APPENDICES section of this policy for additional information about approved clinical trials.
CLUSTER HEADACHES (CH):
Only a stationary gaseous oxygen system (E0424) and related contents (E0441) are covered for the treatment of cluster headaches for beneficiaries enrolled in a clinical trial approved by CMS which are in compliance with the requirements described in the CMS National Coverage Determination Manual (Internet Only Manual 100-03) §240.2.2 for dates of service on or after 01/04/2011. This section states, in part:
Only those beneficiaries diagnosed with the condition of cluster headache are eligible for participation in a clinical study. CMS adopts the diagnostic criteria used by the International Headache Society to form a definitive diagnosis of CH. Therefore, the home use of oxygen to treat CH is covered by Medicare only when furnished to Medicare beneficiaries who have had at least five severe to very severe unilateral headache attacks lasting 15-180 minutes when untreated. (Intensity of pain: Degree of pain usually expressed in terms of its functional consequence and scored on a verbal 5-point scale: 0=no pain; 1=mild pain, does not interfere with usual activities; 2=moderate pain, inhibits but does not wholly prevent usual activities; 3=severe pain, prevents all activities; 4=very severe pain. It may also be expressed on a visual analogue scale.)
The headaches must be accompanied by at least one of the following findings:
Ipsilateral conjunctival injection and/or lacrimation; or
Ipsilateral nasal congestion and/or rhinorrhea; or
Ipsilateral eyelid edema; or
Ipsilateral forehead and facial sweating; or
Ipsilateral miosis and/or ptosis; or
A sense of restlessness or agitation
Claims for oxygen equipment not meeting the criteria above will be denied as not reasonable and necessary.
Claims for stationary oxygen equipment other than E0424 and all portable oxygen equipment used for cluster headaches will be denied as not reasonable and necessary.
Claims for E0424 and E0441 used to treat cluster headaches follow the same payment rules for all other covered oxygen equipment. Refer to the related Policy Article for information on statutory payment rules and coding guidelines to be used for these claims.
Refer to the APPENDICES section of this policy for additional information about approved clinical trials.
Reference Diagnosis Codes that Support Medical Necessity section for applicable diagnoses.
TESTING SPECIFICATIONS:
General
For purposes of this policy:
“Blood gas study” shall refer to both arterial blood gas (ABG) studies and pulse oximetry
“Oximetry” shall refer to routine or “spot” pulse oximetry
“Overnight oximetry” shall refer to 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.
Refer to the Positive Airway Pressure Devises used for the Treatment of Obstructive Sleep Apnea policy for information on sleep tests used for the diagnosis of sleep apnea.
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. This includes a requirement that the test be performed by a provider who is qualified to bill Medicare for the test – i.e., a Part A provider, a laboratory, an Independent Diagnostic Testing Facility (IDTF), or a physician. A supplier is not considered a qualified provider or a qualified laboratory for purposes of this policy. Blood gas studies performed by a supplier are not acceptable. In addition, the qualifying blood gas study may not be paid for by any supplier. These prohibitions do not extend to blood gas studies performed by a hospital certified to do such tests.
The qualifying blood gas study may be performed while the beneficiary is on oxygen as long as the reported blood gas values meet the Group I or Group II criteria.
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. If an ABG test done at rest and awake is non-qualifying, but either an exercise or sleep oximetry test on the same day is qualifying, the exercise or oximetry test result will determine coverage.
All oxygen qualification testing must be performed in-person by a physician or other medical professional qualified to conduct oximetry testing. With the exception of overnight oximetry (see below), unsupervised or remotely supervised home testing does not qualify as a valid test for purposes of Medicare reimbursement of home oxygen and oxygen equipment.
Exercise testing
When oxygen is covered based on an oximetry study obtained during exercise, there must be documentation of three (3) oximetry studies in the beneficiary’s medical record. (1) Testing at rest without oxygen, (2) testing during exercise without oxygen, and (3) testing during exercise with oxygen applied (to demonstrate the improvement of the hypoxemia) are required. All 3 tests must be performed within the same testing session. Exercise testing must be performed in-person by a physician or other medical professional qualified to conduct exercise oximetry testing. Unsupervised or remotely supervised home exercise testing does not qualify as a valid test for purposes of Medicare reimbursement of home oxygen and oxygen equipment. Only the testing during exercise without oxygen is used for qualification and reported on the CMN. The other two results do not have to be routinely submitted but must be available on request.
Oximetry obtained after exercise while resting, sometimes referred to as “recovery” testing, is not part of the three required test elements and is not valid for determining eligibility for oxygen coverage.
Overnight Oximetry Studies:
Overnight sleep oximetry may be performed in a facility or at home. For home overnight oximetry studies, the oximeter provided to the beneficiary must be tamper-proof and must have the capability to download data that allows documentation of the duration of oxygen desaturation below a specified value.
For all the overnight oximetry criteria described above, the 5 minutes does not have to be continuous. Baseline saturation is defined as the mean saturation level during the duration of the test. For purposes of meeting criterion 3 described in Group I above there must be a minimum of 2 hours test time recorded for sleep oximetry. The result must reach a qualifying test value otherwise the Group III presumption of non-coverage applies.
Home overnight oximetry is limited solely to stand-alone overnight pulse oximetry performed in the beneficiary’s home under the conditions specified below. Overnight oximetry performed as part of home sleep testing or as part of any other home testing is not considered to be eligible under this provision to be used for qualification for reimbursement of home oxygen and oxygen equipment even if the testing was performed in compliance with the requirements of this section.
Beneficiaries may self-administer home based overnight oximetry tests under the direction of a Medicare-enrolled Independent Diagnostic Testing Facility (IDTF). A DME supplier or another shipping entity may deliver a pulse oximetry test unit and related technology to a beneficiary’s home under the following circumstances:
The beneficiary’s treating physician has contacted the IDTF to order an overnight pulse oximetry test before the test is performed.
The test is performed under the direction and/or instruction of a Medicare-approved IDTF. Because it is the beneficiary who self-administers this test, the IDTF must provide clear written instructions to the beneficiary on proper operation of the test equipment and must include access to the IDTF in order to address other concerns that may arise. The DME supplier may not create this written instruction, provide verbal instructions, answer questions from the beneficiary, apply or demonstrate the application of the testing equipment to the beneficiary, or otherwise participate in the conduct of the test.
The test unit is sealed and tamper-proof such that test results cannot be accessed by anyone other than the IDTF which is responsible for transmitting a test report to the treating physician. The DME supplier may use related technology to download test results from the testing unit and transmit those results to the IDTF. In no case may the DME supplier access or manipulate the test results in any form.
The IDTF must send the test results to the physician. The IDTF may send the test results to the supplier if the supplier is currently providing or has an order to provide oxygen or other respiratory services to the beneficiary or if the beneficiary has signed a release permitting the supplier to receive the report.
Oximetry test results obtained through a similar process as described for home overnight oximetry (see above) while the beneficiary is awake, either at rest or with exercise, may not be used for purposes of qualifying the beneficiary for home oxygen therapy.
Overnight oximetry does not include oximetry obtained during polysomnography or other sleep testing for sleep apnea, regardless of the location the testing was performed. See below for information on sleep testing that may be used to qualify for oxygen coverage.
Obstructive Sleep Apnea (OSA), Polysomnography and Home Sleep Tests:
Some beneficiaries may require the simultaneous use of home oxygen therapy with a PAP device. To be considered for simultaneous coverage, all requirements in the Coverage Indications, Limitations and/or Medical Necessity for both the Oxygen and Oxygen Equipment and Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea LCDs must be met. Consequently, in addition to this Oxygen LCD, suppliers should refer to the Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea LCD and related Policy Article for additional coverage, coding and documentation requirements.
Coverage of home oxygen therapy requires that the beneficiary be tested in the “chronic stable state.” Chronic stable state is a requirement of the National Coverage Determination (CMS Internet-only Manual, Pub. 100-03, Section 240.2) and is one of the key criteria when determining coverage of home oxygen therapy. The NCD defines chronic stable state as “…not during a period of an acute illness or an exacerbation of their underlying disease.” Based on this NCD definition, all co-existing diseases or conditions that can cause hypoxia must be treated and the beneficiary must be in a chronic stable state before oxygen therapy is considered eligible for payment. In addition, the beneficiary must have a severe lung disease, such as chronic obstructive pulmonary disease, diffuse interstitial lung disease, cystic fibrosis, bronchiectasis, widespread pulmonary neoplasm, or hypoxia-related symptoms or findings that might be expected to improve with oxygen therapy. In the case of OSA, it is required that the OSA be appropriately and sufficiently treated such that the beneficiary is in the chronic stable state before oxygen saturation results obtained during sleep testing are considered qualifying for oxygen therapy (see PAP LCD for additional information).
For beneficiaries with OSA, this means that the OSA must be sufficiently treated such that the underlying severe lung disease is unmasked. This must be demonstrated before oxygen saturation results obtained during polysomnography are considered qualifying for oxygen therapy.
For beneficiaries 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:
The titration is conducted over a minimum of two (2) hours; and
During titration:
The AHI/RDI is reduced to less than or equal to an average of ten (10) events per hour; or
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
Nocturnal oximetry conducted for the purpose for oxygen reimbursement qualification may only be performed after optimal PAP settings have been determined and the beneficiary is using the PAP device at those settings; and
The nocturnal oximetry conducted during the PSG demonstrates an oxygen saturation = 88% for 5 minutes total (which need not be continuous)
If all of the above criteria are met, for the purposes of a qualifying oxygen saturation test, the beneficiary is considered to be in the “chronic stable state.” To be eligible for Medicare coverage and payment for home oxygen therapy for concurrent use with PAP therapy, in addition to being in the chronic stable state, the beneficiary must meet all other coverage requirements for oxygen therapy. Beneficiaries that qualify for oxygen therapy based on testing conducted only during the course of a sleep test are eligible only for reimbursement of stationary equipment.
Overnight oximetry performed as part of home sleep testing or as part of any other home testing is not considered as eligible to be used for qualification for reimbursement of home oxygen and oxygen equipment (see overnight oximetry section above for additional information).
Claims for oxygen equipment and supplies for beneficiaries who do not meet the coverage requirements for home oxygen therapy will be denied as not reasonable and necessary.
CERTIFICATION:
An Initial, Recertification, or Revised CMN must be obtained and submitted in the situations described below. The Initial Date, Recertification Date, and Revised Date specified below refer to the dates reported in Section A of the CMN.
Initial CMN is required:
With the first claim for home oxygen, (even if the beneficiary was on oxygen prior to Medicare eligibility or oxygen was initially covered by a Medicare HMO).
During the first 36 months of the rental period, when there has been a change in the beneficiary’s condition that has caused a break in medical necessity of at least 60 days plus whatever days remain in the rental month during which the need for oxygen ended. Refer to the Policy Article NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES for additional information.
When the equipment is replaced because the reasonable useful lifetime of prior equipment has been reached.
When the equipment is replaced because of irreparable damage, theft, or loss of the originally dispensed equipment.
Irreparable damage refers to a specific accident or to a natural disaster [e.g., fire, flood]
Irreparable damage does not refer to wear and tear over time
Testing and Visit Requirements:
Initial CMN for situations 1 and 2
The blood gas study must be the most recent study obtained within 30 days prior to the Initial Date.
For situation 1, there is an exception to the 30-day test requirement for beneficiaries who were started on oxygen while enrolled in a Medicare HMO and transition to fee-for-service Medicare. For those beneficiaries, the blood gas study does not have to be obtained 30 days prior to the Initial Date, but must be the most recent qualifying test obtained while in the HMO.
The beneficiary must be seen and evaluated by the treating physician within 30 days prior to the date of Initial Certification.
Initial CMN for scenarios 3 and 4 (replacement equipment)
Repeat blood gas testing is not required. Enter the most recent qualifying value and test date. This test does not have to be within 30 days prior to the Initial Date. It could be the test result reported on the most recent prior CMN.
There is no requirement for a physician visit that is specifically related to the completion of the CMN for replacement equipment.
Recertification CMN is required:
12 months after Initial Certification, (i.e., with the thirteenth month’s claim) for Group I
3 months after Initial Certification, (i.e., with the fourth month’s claim) for Group II
Testing and Visit Requirements:
Recertification following initial certification situations 1 and 2
For beneficiaries initially meeting Group I criteria, the most recent qualifying blood gas study prior to the thirteenth month of therapy must be reported on the Recertification CMN.
For beneficiaries initially meeting Group II criteria, the most recent blood gas study that was performed between the 61st and 90th day following Initial Certification must be reported on the Recertification CMN. If a qualifying test is not obtained between the 61st and 90th day of home oxygen therapy but the beneficiary continues to use oxygen and a test is obtained at a later date, if that test meets Group I or II criteria, coverage would resume beginning with the date of that test.
For beneficiaries initially meeting group I or II criteria, the beneficiary must be seen and re-evaluated by the treating physician within 90 days prior to the date of any Recertification. If the physician visit is not obtained within the 90-day window but the beneficiary continues to use oxygen and the visit is obtained at a later date, coverage would resume beginning with the date of that visit.
Recertification following initial situations 3 and 4 (replacement equipment)
Repeat testing is not required. Enter the most recent qualifying value and test date. This test does not have to be within 30 days prior to the Initial Date. It could be the test result reported on the most recent prior CMN.
There is no requirement for a physician visit that is specifically related to the completion of the CMN for replacement equipment.
Revised CMN is required:
When the prescribed maximum flow rate changes from one of the following categories to another:
Less than 1 LPM,
1-4 LPM,
Greater than 4 LPM
If the change is from category (a) or (b) to category (c), a repeat blood gas study with the beneficiary on 4 LPM must be performed.
When the length of need expires – if the physician specified less than lifetime length of need on the most recent CMN
When a portable oxygen system is added subsequent to Initial Certification of a stationary system
When a stationary system is added subsequent to Initial Certification of a portable system
When there is a new treating physician but the oxygen order is the same
If there is a new supplier and that supplier does not have the prior CMN
Submission of a Revised CMN does not change the Recertification schedule specified above.
If the indications for a Revised CMN are met at the same time that a Recertification CMN is due, file the CMN as a Recertification CMN.
Testing and Visit Requirements:
None of the Revised Certification situations (7-12) require a physician visit.
Revised Certification situations 7 and 8
The blood gas study must be the most recent study obtained within 30 days prior to the Initial Date.
Revised Certification situation 9
There is no requirement for a repeat blood gas study unless the initial qualifying study was performed during sleep, in which case a repeat blood gas study must be performed while the beneficiary is at rest (awake) or during exercise within 30 days prior to the Revised Date.
Revised Certifications situations 10-12
No blood gas study is required
For situations 11 and 12, the revised certification does NOT have to be submitted with the claim.
General:
Beneficiaries do not change group classification going from an initial certification to a recertification based upon changes in blood oxygen testing results. For example: A beneficiary initially qualifies for group II with an 89% oximetry value. At the 3-month retest a result of 87% is obtained. Despite the group I retesting value, the beneficiary remains in group II. There is no reclassification to group I. Further recertification is not required unless:
A non-qualifying test result is obtained at the time of recertification but the beneficiary later obtains a qualifying test result; or,
The specified length of need (LON) is reached.
Generally only one recertification is required regardless of group classification unless the LON specified on the recertification CMN is some value other than 99 (indicating lifetime). If other than lifetime is specified the certification will expire when the specified LON time period elapses. A recertification will be required to continue coverage.
Recertification is required to be completed on or prior to the end of the initial certification period. If timely recertification is not completed by the end of the initial certification period, reimbursement ends until the recertification is completed. At such time that the recertification requirements are met, payment will resume at the month in the rental cycle where the rental was stopped due to the expiration of the initial certification. A new, initial rental cycle does not begin when the recertification requirements are met.
A completed and signed Certificate of Medical Necessity (CMN) is required to receive payment for oxygen. Claims submitted without a valid CMN will be denied as not reasonable and necessary.
PORTABLE OXYGEN SYSTEMS:
A portable oxygen system is covered if the beneficiary is mobile within the home 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 will be denied as not reasonable and necessary.
If coverage criteria are met, a portable oxygen system is usually separately payable in addition to the stationary system. See exception in the related Policy Article Non-Medical Necessity Coverage and Payment Rules, OXYGEN EQUIPMENT, Initial 36-Months section.
If a portable oxygen system is covered, the supplier must provide whatever quantity of oxygen the beneficiary uses; Medicare’s reimbursement is the same, regardless of the quantity of oxygen dispensed.
LITER FLOW GREATER THAN 4 LPM:
If basic oxygen coverage criteria have been met, a higher allowance for a stationary system for a flow rate of greater than 4 liters per minute (LPM) will be paid only if a blood gas study performed while the beneficiary is on 4 or more LPM meets Group I or II criteria. If a flow rate greater than 4 LPM is billed and the coverage criterion for the higher allowance is not met, payment will be limited to the standard fee schedule allowance. (Refer to related Policy Article for additional information on payment for greater than 4 LPM oxygen.)
MISCELLANEOUS:
Oxygen reimbursement is a bundled payment. All options, supplies and accessories are considered included in the monthly rental payment for oxygen equipment. Oxygen rental is billed using the appropriate code for the provided oxygen equipment. Separately billed options, accessories or supply items will be denied as unbundling.
Emergency or stand-by oxygen systems for beneficiaries who are not regularly using oxygen will be denied as not reasonable and necessary since they are precautionary and not therapeutic in nature.
Topical hyperbaric oxygen chambers (A4575) will be denied as not reasonable and necessary. (IOM 100-03 20.29(B) & (C))
Topical oxygen delivery systems (E0446) will be denied as not reasonable and necessary. (IOM 100-03 20.29(C))
REFILLS OF OXYGEN CONTENTS:
For Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items and supplies provided on a recurring basis, billing must be based on prospective, not retrospective use.
Oxygen contents are reimbursed with a monthly allowance covering all contents necessary for the month. Supply allowances are not subject to the refill monitoring and documentation requirements specified by Medicare Program Integrity Manual section 5.2.6.
All other supplies, e.g. tubing, masks or cannulas, etc., are included in the monthly rental payment. Supplies that are not separately payable are not subject to the refill monitoring and documentation requirements specified by Medicare Program Integrity Manual section 5.2.6.
See the Non-Medical Coverage and Payment Rules section of the related Policy Article for additional information about coverage of oxygen contents.
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
N/A
Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
N/A
CPT/HCPCS Codes
Group 1 Paragraph: The appearance of a code in this section does not necessarily indicate coverage.
HCPCS MODIFIERS:
EY – No physician or other licensed health care provider order for this item or service
Q0 (Q-zero) - Investigational clinical service provided in a clinical research study that is in an approved clinical research study
QE - Prescribed amount of oxygen is less than 1 liter per minute (LPM)
QF - Prescribed amount of oxygen is greater than 4 liter per minute (LPM) and portable oxygen is prescribed
QG - Prescribed amount of oxygen is greater than 4 liters per minute (LPM)
QH - Oxygen conserving device is being used with an oxygen delivery system
Origin/Destination modifiers for Medicare
Modifier Listing for Medicare Part B
Origin/Destination modifiers
D Diagnostic or therapeutic site
E Residential, custodial facility
G Hospital-based dialysis facility
H Hospital
I Site of transfer between modes of ambulance transfer
J Non-hospital based dialysis facility
N Skilled nursing facility
P Physician’s office
R Residence
S Scene of accident or acute event
X Intermediate stop at physician’s office on the way to the hospital
Origin/Destination modifiers
D Diagnostic or therapeutic site
E Residential, custodial facility
G Hospital-based dialysis facility
H Hospital
I Site of transfer between modes of ambulance transfer
J Non-hospital based dialysis facility
N Skilled nursing facility
P Physician’s office
R Residence
S Scene of accident or acute event
X Intermediate stop at physician’s office on the way to the hospital
Medicare modifier list - AA - GP
Modifier Listing for Medicare Part B
AA Anesthesia performed by anesthesiologist
AD Supervision by anesthesiologist of more than 4 concurrent anesthesia
AE Registered Dietician
AF Specialty Physician
AH Clinical psychologist
AJ Licensed clinical social worker
AM Physician services, team member services
AR Physician providing service in a physician scarcity area
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
AT Active/corrective treatment for chiropractic service only
CB Services ordered by a dialysis facility physician as part of the ESRD beneficiary’s dialysis benefit,
is not part of the composite rate, and is separately reimbursable.
CC Procedure code change or a change in provider charges resolution
DD Powdered enteral supplies
EJ Subsequent claims for a defined course of therapy
E1 Upper left, eyelid
E2 Lower left, eyelid
E3 Upper right, eyelid
E4 Lower right, eyelid
FA Left hand, thumb
FP Services provided as part of family planning program
F1 Left hand, second digit
F2 Left hand, third digit
F3 Left hand, fourth digit
F4 Left hand, fifth digit
F5 Right hand, thumb
F6 Right hand, second digit
F7 Right hand, third digit
F8 Right hand, fourth digit
F9 Right hand, fifth digit
GA Waiver of liability statement on file
GC Teaching physician services that meet the requirement
GE Teaching physician services rendered under exemption to policy
GG Performance and payment of a screening mammography and diagnostic mammography on same patient same day.
GH Diagnostic mammography to screening mammography
GJ Opt out physician or practitioner emergency or urgent services
GN Services delivered under an outpatient speech-language pathology plan of care
GO Services delivered under an outpatient OT plan of care
GP Services delivered under an outpatient PT plan of care
AA Anesthesia performed by anesthesiologist
AD Supervision by anesthesiologist of more than 4 concurrent anesthesia
AE Registered Dietician
AF Specialty Physician
AH Clinical psychologist
AJ Licensed clinical social worker
AM Physician services, team member services
AR Physician providing service in a physician scarcity area
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
AT Active/corrective treatment for chiropractic service only
CB Services ordered by a dialysis facility physician as part of the ESRD beneficiary’s dialysis benefit,
is not part of the composite rate, and is separately reimbursable.
CC Procedure code change or a change in provider charges resolution
DD Powdered enteral supplies
EJ Subsequent claims for a defined course of therapy
E1 Upper left, eyelid
E2 Lower left, eyelid
E3 Upper right, eyelid
E4 Lower right, eyelid
FA Left hand, thumb
FP Services provided as part of family planning program
F1 Left hand, second digit
F2 Left hand, third digit
F3 Left hand, fourth digit
F4 Left hand, fifth digit
F5 Right hand, thumb
F6 Right hand, second digit
F7 Right hand, third digit
F8 Right hand, fourth digit
F9 Right hand, fifth digit
GA Waiver of liability statement on file
GC Teaching physician services that meet the requirement
GE Teaching physician services rendered under exemption to policy
GG Performance and payment of a screening mammography and diagnostic mammography on same patient same day.
GH Diagnostic mammography to screening mammography
GJ Opt out physician or practitioner emergency or urgent services
GN Services delivered under an outpatient speech-language pathology plan of care
GO Services delivered under an outpatient OT plan of care
GP Services delivered under an outpatient PT plan of care
Medicare part b coverd modiferi list GQ - Q1
Modifier Listing for Medicare Part B
GQ Via asynchronous telecommunications system
GT Via interactive audio and video telecommunication system
GV Attending physician not employed or paid under agreement by the patient’s hospice provider
GW Services not related to the hospice patient’s terminal condition
GY Item or service statutorily non-covered or is not a Medicare benefit
GZ Item or service may not be reasonable and necessary
G1 Most recent URR reading of less than 60
G2 Most recent URR reading of 60 to 64.9
G3 Most recent URR reading of 65 to 69.9
G4 Most recent URR reading of 70 to 74.9
G5 Most recent URR reading of 75 or greater
G6 ESRD patient for whom less than 6 dialysis sessions have been provided in a month
G7 Pregnancy resulted from rape or incest, or pregnancy certified by physician as life threatening
G8 Monitored anesthesia care for deep, complex, complicated or marked invasive surgical procedure
G9 Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition
J1 Competitive Acquisition Program (CAP) “ no pay for prescription number
J2 Competitive Acquisition Program (CAP) restock of emergency drug
J3 Competitive Acquisition Program (CAP) drug unavailable as written
JA Administered intravenously
JB Administered subcutaneously
JW Discarded drug not administered
KO Single drug unit dose formulation
KP First drug of multiple drug unit dose formulation
KQ Second or subsequent drug of a multiple drug unit dose formulation
KS Glucose monitor supply for diabetic beneficiary not treated with insulin
KZ New coverage not implemented by managed care
LC Left circumflex coronary artery
LD Left anterior descending coronary artery
LR Laboratory round trip
LS FDA-monitored intraocular lens implant
LT Left side of the body
M2 Competitive Acquisition Program (CAP) Medicare secondary payer
QB Physician providing services in a rural HPSA
QC Single channel cardiac monitoring
QJ Services/items provided to a prisoner or patient in a state or local custody, however, the state or
local government, as applicable, meets requirements in 42 CFR 411.4(B)
QK Medical direction of two, three or four concurrent anesthesia
QP Documentation is on file showing that the laboratory test(s) was ordered individually
QQ Service for which a statement of intent was submitted, deemed as valid, and an acknowledgment letter was received
QS Monitored anesthesia care service
QT Recording and storage on tape by an analog tape recorder
QU Physician providing services in an urban HPSA
QW CLIA waived lab tests
QX CRNA anesthesia with medical direction
QY Anesthesiologist medically directs one CRNA
QZ CRNA anesthesia without medical direction
Q0 Item/service in Medicare study
Q1 Item or service provided as routine care in a Medicare Clinical Research study
GQ Via asynchronous telecommunications system
GT Via interactive audio and video telecommunication system
GV Attending physician not employed or paid under agreement by the patient’s hospice provider
GW Services not related to the hospice patient’s terminal condition
GY Item or service statutorily non-covered or is not a Medicare benefit
GZ Item or service may not be reasonable and necessary
G1 Most recent URR reading of less than 60
G2 Most recent URR reading of 60 to 64.9
G3 Most recent URR reading of 65 to 69.9
G4 Most recent URR reading of 70 to 74.9
G5 Most recent URR reading of 75 or greater
G6 ESRD patient for whom less than 6 dialysis sessions have been provided in a month
G7 Pregnancy resulted from rape or incest, or pregnancy certified by physician as life threatening
G8 Monitored anesthesia care for deep, complex, complicated or marked invasive surgical procedure
G9 Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition
J1 Competitive Acquisition Program (CAP) “ no pay for prescription number
J2 Competitive Acquisition Program (CAP) restock of emergency drug
J3 Competitive Acquisition Program (CAP) drug unavailable as written
JA Administered intravenously
JB Administered subcutaneously
JW Discarded drug not administered
KO Single drug unit dose formulation
KP First drug of multiple drug unit dose formulation
KQ Second or subsequent drug of a multiple drug unit dose formulation
KS Glucose monitor supply for diabetic beneficiary not treated with insulin
KZ New coverage not implemented by managed care
LC Left circumflex coronary artery
LD Left anterior descending coronary artery
LR Laboratory round trip
LS FDA-monitored intraocular lens implant
LT Left side of the body
M2 Competitive Acquisition Program (CAP) Medicare secondary payer
QB Physician providing services in a rural HPSA
QC Single channel cardiac monitoring
QJ Services/items provided to a prisoner or patient in a state or local custody, however, the state or
local government, as applicable, meets requirements in 42 CFR 411.4(B)
QK Medical direction of two, three or four concurrent anesthesia
QP Documentation is on file showing that the laboratory test(s) was ordered individually
QQ Service for which a statement of intent was submitted, deemed as valid, and an acknowledgment letter was received
QS Monitored anesthesia care service
QT Recording and storage on tape by an analog tape recorder
QU Physician providing services in an urban HPSA
QW CLIA waived lab tests
QX CRNA anesthesia with medical direction
QY Anesthesiologist medically directs one CRNA
QZ CRNA anesthesia without medical direction
Q0 Item/service in Medicare study
Q1 Item or service provided as routine care in a Medicare Clinical Research study
Medicare covered modifier list - part B
Modifier Listing for Medicare Part B
Q3 Live kidney donor
Q4 Services for ordering or referring physician qualifies as a service exemption
Q5 Services provided by substitute physician under reciprocal billing
Q6 Services furnished by a locum tenens physician
Q7 One class A finding
Q8 Two class B findings
Q9 One class B finding and two class C findings
RC Right coronary artery
RT Right side of body
SF Second opinion ordered by provider
SG Ambulatory surgical center facility fee
TA Left foot, great toe
TC Technical component only
TS Follow up service
T1 Left foot, second digit
T2 Left foot, third digit
T3 Left foot, fourth digit
T4 Left foot, fifth digit
T5 Right foot, great toe
T6 Right foot, second digit
T7 Right foot, third digit
T8 Right foot, fourth digit
T9 Right foot, fifth digit
UN Portable X-ray – two patients served
UP Portable X-ray – three patients served
UQ Portable X-ray – four patients served
UR Portable X-ray – five patients served
US Portable X-ray – six or more patients served
VP Aphakic patient
1P PQRI Performance Measure Exclusion due to medical reason
21 Prolonged E/M service
22 Specific unusual or difficult services
23 Unusual anesthesia
24 Unrelated E/M or eye exam during post-op by same provider
25 Separate E/M on the same day as another service by same provider.
26 Professional component
2P PQRI Performance Measure Exclusion due to patient reason
32 Services related to mandated consultation and or related service
3P PQRI Performance Measure Exclusion due to system reason
47 Anesthesia by surgeon
50 Bilateral procedure
51 Multiple surgical procedures on same day
52 Less than usual service
53 Discontinued Procedure
54 Surgical procedure only, no follow-up care
55 Follow-up care only
56 Pre-operative management only
57 Decision for surgery
58 Related service by same physician during post-operative
59 Distinct procedural service
60 Altered surgical field
62 Two surgeons
66 Surgical team
73 Discontinued procedure pre-anesthesia
74 Discontinued procedure post-anesthesia
76 Repeat procedure, same provider
77 Repeat procedure, different provider
78 Return to operating room for a related service, post-operative
79 Unrelated procedure, same physician, post-operative
80 Assistant surgeon above minimum fee
81 Assistant surgeon at minimum fee
82 Assistant surgeon – when qualified resident is not available
8P PQRI Performance Reporting-action not performed, reason NOS
91 Repeat clinical diagnostic laboratory test
99 Multiple modifiers
Q3 Live kidney donor
Q4 Services for ordering or referring physician qualifies as a service exemption
Q5 Services provided by substitute physician under reciprocal billing
Q6 Services furnished by a locum tenens physician
Q7 One class A finding
Q8 Two class B findings
Q9 One class B finding and two class C findings
RC Right coronary artery
RT Right side of body
SF Second opinion ordered by provider
SG Ambulatory surgical center facility fee
TA Left foot, great toe
TC Technical component only
TS Follow up service
T1 Left foot, second digit
T2 Left foot, third digit
T3 Left foot, fourth digit
T4 Left foot, fifth digit
T5 Right foot, great toe
T6 Right foot, second digit
T7 Right foot, third digit
T8 Right foot, fourth digit
T9 Right foot, fifth digit
UN Portable X-ray – two patients served
UP Portable X-ray – three patients served
UQ Portable X-ray – four patients served
UR Portable X-ray – five patients served
US Portable X-ray – six or more patients served
VP Aphakic patient
1P PQRI Performance Measure Exclusion due to medical reason
21 Prolonged E/M service
22 Specific unusual or difficult services
23 Unusual anesthesia
24 Unrelated E/M or eye exam during post-op by same provider
25 Separate E/M on the same day as another service by same provider.
26 Professional component
2P PQRI Performance Measure Exclusion due to patient reason
32 Services related to mandated consultation and or related service
3P PQRI Performance Measure Exclusion due to system reason
47 Anesthesia by surgeon
50 Bilateral procedure
51 Multiple surgical procedures on same day
52 Less than usual service
53 Discontinued Procedure
54 Surgical procedure only, no follow-up care
55 Follow-up care only
56 Pre-operative management only
57 Decision for surgery
58 Related service by same physician during post-operative
59 Distinct procedural service
60 Altered surgical field
62 Two surgeons
66 Surgical team
73 Discontinued procedure pre-anesthesia
74 Discontinued procedure post-anesthesia
76 Repeat procedure, same provider
77 Repeat procedure, different provider
78 Return to operating room for a related service, post-operative
79 Unrelated procedure, same physician, post-operative
80 Assistant surgeon above minimum fee
81 Assistant surgeon at minimum fee
82 Assistant surgeon – when qualified resident is not available
8P PQRI Performance Reporting-action not performed, reason NOS
91 Repeat clinical diagnostic laboratory test
99 Multiple modifiers
ABN notice -does patient need to sign every visit ? GA, GZ, GY modifier -
Does a beneficiary need to sign an Advance Beneficiary of Noncoverage (ABN) for every visit?
Answer:
Notifiers are required to issue ABNs when an item or service is expected to be denied based on one of the provisions in the Medicare Claims Processing Manual Chapter 30 §50.5. This may occur at any one of three points during a course of treatment which are initiation, reduction, and termination, also known as 'triggering events.'
Initiations
An initiation is the beginning of a new patient encounter, start of a plan of care, or beginning of treatment. If a notifier believes that certain otherwise covered items or services will be non-covered (e.g., not reasonable and necessary) at initiation, an ABN must be issued prior to the beneficiary receiving the non-covered care.
Example: Mrs. S. asks her physician for an EKG because her sister was recently diagnosed with atrial fibrillation. Mrs. S. has no diagnosis that warrants medical necessity of an EKG but insists on having an EKG even if she has to pay out of pocket for it. The physician’s office personnel issue an ABN to Mrs. S. before the EKG is done.
Reductions
A reduction occurs when there is a decrease in a component of care (i.e., frequency, duration, etc.). The ABN is not issued every time an item or service is reduced. But, if a reduction occurs and the beneficiary wants to receive care that is no longer considered medically reasonable and necessary, the ABN must be issued prior to delivery of this non-covered care.
Example: Mr. T, is receiving outpatient physical therapy five days a week, and after meeting several goals, therapy is reduced to three days per week. Mr. T wants to achieve a higher level of proficiency in performing goal related activities and wants to continue with therapy five days a week. He is willing to take financial responsibility for the costs of the two days of therapy per week that are no longer medically reasonable and necessary. An ABN would be issued prior to providing the additional days of therapy weekly.
Terminations
A termination is the discontinuation of certain items or services. The ABN is only issued at termination if the beneficiary wants to continue receiving care that is no longer medically reasonable and necessary.
Example: Ms. X has been receiving covered outpatient speech therapy services, has met her treatment goals, and has been given speech exercises to do at home that do not require therapist intervention. Ms. X wants her speech therapist to continue to work with her even though continued therapy is not medically reasonable or necessary. Ms. X is issued an ABN prior to her speech therapist resuming therapy that is no longer considered medically reasonable and necessary.
Period of Effectiveness/ Repetitive or Continuous Noncovered Care
An ABN can remain effective for up to one year. Notifiers may give a beneficiary a single ABN describing an extended or repetitive course of noncovered treatment provided that the ABN lists all items and services that the notifier believes Medicare will not cover. If applicable, the ABN must also specify the duration of the period of treatment. If there is any change in care from what is described on the ABN within the one-year period, a new ABN must be given. If during the course of treatment additional noncovered items or services are needed, the notifier must give the beneficiary another ABN. The limit for use of a single ABN for an extended course of treatment is one year. A new ABN is required when the specified treatment extends beyond one year.
If a beneficiary is receiving repetitive non-covered care, but the provider or supplier failed to issue an ABN before the first or the first few episodes of care were provided, the ABN may be issued at any time during the course of treatment. However, if the ABN is issued after repetitive treatment has been initiated; the ABN cannot be retroactively dated or used to shift liability to the beneficiary for care that had been provided before ABN issuance.
ADVANCED BENEFICIARY NOTIFICATION
Medicare screening services are limited to a specific frequency (e.g., once every 2 years, once every year). A physician may not know whether a patient is eligible for this service in a given year. If she is not eligible, the service will be denied. Therefore, the physician should ask the patient to sign an advance beneficiary notice of noncoverage (ABN) using the form provided by Medicare. For more information on Medicare’s ABN form, visit http://www.cms.hhs.gov/BNI/02_ABN.asp. Claims for
Medicare patients should be submitted with the appropriate HCPCS modifier.
• GA modifier indicates that an ABN form has been signed.
• GZ modifier indicates that an ABN form has not been signed. (Item or service expected to be denied as not reasonable and necessary)
• GY modifier indicates that the service provided is not a covered Medicare benefit. The service is being reported to Medicare in order to receive a denial.
Using the appropriate modifier ensures that the patient will receive the correct information on her Explanation of Benefits (EOB). For example, when a service is reported with a GY modifier, the EOB will state that it is not covered and therefore is the patient’s responsibility.
Comparison of Modifier 57 and -25 Modifier
Modifier -57
• Decision for major surgery based upon the E/M done today
• Major procedure for Medicare/Medicaid
• Any procedure for commercial insurance
Modifier -25
• Separately and identifiable E/M service on same day as a minor surgical procedure.
• Document your E&M well and keep any procedure documentation as a separate part of your note.
• Used with minor procedure for Medicare or for commercial insurance
• Decision for major surgery based upon the E/M done today
• Major procedure for Medicare/Medicaid
• Any procedure for commercial insurance
Modifier -25
• Separately and identifiable E/M service on same day as a minor surgical procedure.
• Document your E&M well and keep any procedure documentation as a separate part of your note.
• Used with minor procedure for Medicare or for commercial insurance
Medicare DME modifiers and HCPCS modifiers
DME Modifiers
-KX Requirements specified in medical policy have been met.
-EY No physician or other licensed health care provider order for this item or service (Items
billed to the DMERC before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code)
HCPCS Modifiers
-GJ “OPT OUT” physician providing emergency / urgent care
-GP Services were provided under an outpatient physical therapy plan of care
-GWService not related to hospice patient’s terminal care (used when a hospice patient is seen,but services are unrelated to the terminal condition)
- AQ (replaces QB ad QU) Physician services provided in health provider shortage area (HPSA)
-QW CLIA waived test
-LT Left foot
-TA Left great toe
-T1 2nd toe, left foot
-T2 3rd toe, left foot
-T3 4th toe, left foot
-T4 5th toe, left foot
-RT Right foot
-T5 Right great toe
-T6 2nd toe, right foot
-T7 3rd toe, right foot
-T8 4th toe, right foot
-T9 5th toe, right foot
-Q5 Service provided by substitute physician under reciprocal billing arrangement
-Q6 Services provided by a locum tenens physician
-AS Assistant at Surgery of a physician assistant, nurse practitioner or clinical nurse practitioner
• -GC Service performed in part by resident under direction of teaching physician (informational only)
• -GE Service performed by a resident without the presence of a teaching physician [primary care exception] (informational only)
-Q7 One Class A finding
-Q8 Two Class B findings
-Q9 One Class B and Two Class C findings
-KX Requirements specified in medical policy have been met.
-EY No physician or other licensed health care provider order for this item or service (Items
billed to the DMERC before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code)
HCPCS Modifiers
-GJ “OPT OUT” physician providing emergency / urgent care
-GP Services were provided under an outpatient physical therapy plan of care
-GWService not related to hospice patient’s terminal care (used when a hospice patient is seen,but services are unrelated to the terminal condition)
- AQ (replaces QB ad QU) Physician services provided in health provider shortage area (HPSA)
-QW CLIA waived test
-LT Left foot
-TA Left great toe
-T1 2nd toe, left foot
-T2 3rd toe, left foot
-T3 4th toe, left foot
-T4 5th toe, left foot
-RT Right foot
-T5 Right great toe
-T6 2nd toe, right foot
-T7 3rd toe, right foot
-T8 4th toe, right foot
-T9 5th toe, right foot
-Q5 Service provided by substitute physician under reciprocal billing arrangement
-Q6 Services provided by a locum tenens physician
-AS Assistant at Surgery of a physician assistant, nurse practitioner or clinical nurse practitioner
• -GC Service performed in part by resident under direction of teaching physician (informational only)
• -GE Service performed by a resident without the presence of a teaching physician [primary care exception] (informational only)
-Q7 One Class A finding
-Q8 Two Class B findings
-Q9 One Class B and Two Class C findings
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