Oxygen services are not directly reimbursable for consumers residing in a nursing facility (NF) as defined in section 5111.20 of the Revised Code. Such services are the responsibility of the NF and reimbursed to the NF through the facility per diem. Oxygen services for residents of an intermediate care facility for the mentally retarded (ICF-MR) as defined in section 5111.20 of the Revised Code are covered through direct reimbursement as provided in this rule. The provisions in this rule do not apply to oxygen services provided to the residents of nursing facilities.
(A) Coverage criteria.
(1) A current prescription is required prior to dispensing oxygen. This prescription must be renewed once a year and kept in the consumer's medical record in order to justify a consumer's continued need for oxygen services. Any significant changes to the consumer's treatment plan pertaining to oxygen services require a new prescription be obtained and kept in the consumer's medical record.
A significant change to the consumer's treatment plan pertaining to oxygen services is defined as the point where the consumer's prescribed amount of oxygen requires the use of or change of an oxygen modifier code.
(2) Oxygen services are covered only for consumers with significant hypoxemia in the chronic stable state provided all of the following conditions are met:
(a) The treating prescriber has determined that the consumer has a severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen services; and
(b) The consumer's blood gas and/or oxygen saturation levels indicate the need for oxygen services; and
(c) Alternative treatment measures have been tried or considered and deemed clinically ineffective.
(3) Non-covered diagnoses: oxygen services will be denied as not medically necessary if any of the following conditions are present:
(a) Angina pectoris in the absence of hypoxemia; or
(b) Dyspnea without cor pulmonale or evidence of hypoxemia; or
(c) Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities, but in the absence of systemic hypoxemia; or
(d) Terminal illnesses that do not affect the respiratory system.
(4) A prescription of "Oxygen PRN" that specifies the oxygen flow rate and duration or indications for usage does meet the requirements of this rule.
(B) Coverage requirements.
(1) Covered blood gas and/or oxygen saturation values. A consumer is considered to have significant hypoxemia if group I or II criteria are met.
(a) Group I criteria include any of the following:
(i) An arterial partial pressure (tension) of oxygen (PO2) at or below fifty-five mm Hg, or an arterial oxygen saturation at or below eighty-eight per cent, taken at rest (awake).
(ii) An arterial PO2 at or below fifty-five mm Hg, or an arterial oxygen saturation at or below eighty-eight per cent, taken during sleep, for a patient who demonstrates an arterial PO2 at or above fifty-six mm Hg or an arterial oxygen saturation at or above eighty-nine per cent, while awake.
(iii) A decrease in arterial PO2 more than ten mm Hg, or a decrease in arterial oxygen saturation more than five per cent, taken during sleep, associated with symptoms or signs reasonably attributable to hypoxemia (e.g., cor pulmonale, "P" pulmonale on electrocardiogram (EKG), documented pulmonary hypertension and erythrocytosis). In either of these cases, coverage is provided only for the nocturnal use of oxygen.
(iv) An arterial PO2 at or below fifty-five mm Hg, or an arterial oxygen saturation at or below eighty-eight per cent, taken during exercise, for a patient who demonstrates an arterial PO2 at or above fifty-six mm Hg or an arterial oxygen saturation at or above eighty-nine per cent, during the day while at rest. In this case, supplemental oxygen is provided for use during exercise if it is documented that the use of oxygen improves the hypoxemia that was demonstrated during exercise when the patient was breathing room air.
(b) Group II criteria include any of the following:
(i) An arterial PO2 of fifty-six to fifty-nine mm Hg or an arterial blood oxygen saturation of eighty-nine per cent, taken at rest (awake), during sleep, or during exercise (as described under group I criteria); and
(a) Dependent edema suggesting congestive heart failure; or
(b) 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 three mm in standard leads II, III, or AVF); or
(c) Erthrocythemia with a hematocrit greater than fifty-six per cent.
(2) The provider of oxygen services may conduct the pulse oximetery but may not conduct the arterial blood gas measurement. A blood gas measurement must be conducted by a provider qualified to conduct such tests, other than a durable medical equipment (DME) provider. In addition, the qualifying blood gas or oxygen saturation measurement may not be paid for by any DME provider. However, this prohibition does not extend to blood gas or oxygen saturation measurements performed by a hospital certified to do such testing. When both arterial blood gas (ABG) and oxygen saturation (oximetry) tests have recently been performed, greater weight is given to the ABG result when determining medical necessity for oxygen services.
(C) Prior authorization, documentation and testing.
(1) Prior authorization.
Prior authorization is not required for reimbursement of oxygen services provided to residents in ICFs-MR once the medical necessity of services is established and documented in the provider's file.
(2) Documentation requirements.
(a) Requests for reimbursement submitted by the provider for oxygen services must be corroborated by documentation in the consumer's medical record that demonstrates medicaid coverage criteria have been met. The consumer's medical records could include the prescriber's office records, hospital records, home health agency records, or records from other healthcare professionals. This documentation must be available for review upon request by the Ohio department of job and family services (ODJFS).
(b) The oxygen provider must have on file, prior to submitting any claim for reimbursement, a fully completed form JFS 01909 (rev. 6/2005), "Certificate of Medical Necessity/Prescription for Oxygen Services," (appendix A to this rule), that is signed and dated by the attending prescriber no more than thirty days after the first date of service.
(c) The consumer must be evaluated by the attending prescriber and a prescription written within thirty days prior to the date of initial certification. The consumer must be re-evaluated by the attending prescriber and a prescription written within ninety days prior to the date of any recertification.
(3) Testing requirements.
(a) The consumer's qualifying PO2 or arterial blood oxygen saturation level must be established no earlier than forty-eight hours prior to the initial date of service or the renewal of service and every year thereafter for recertification in order to establish continued medical necessity.
(b) The provider shall keep on file a copy of a laboratory report of an arterial blood gas (ABG) study that has been ordered evaluated and countersigned by the attending prescriber.
(c) Documentation of pulse oximeter results may be kept on file in lieu of an ABG when ordered, evaluated and countersigned by the attending prescriber. If this occurs, a copy of the dated oximetry print-out or dated form used to document the oximetry results, signed and dated by the prescriber, shall be kept in the provider's file.
(d) All tests for oxygen saturation shall be performed while the consumer is in a chronic stable state and not during a period of acute illness or an exacerbation of the consumer's underlying disease.
(D) Modifier requirements.
To receive a payment adjustment, one of the following modifiers must be used with the oxygen system codes specified in paragraph (E) of this rule when appropriate. Oxygen concentrators are not subject to these modifiers.
(1) No modifier is used when:
(a) The prescribed amount of oxygen is greater than one liter per minute and no more than four liters per minute; or
(b) Supplying portable oxygen contents or a portable system rental; or
(c) The prescribed amount of oxygen is greater than four liters per minute non-continuous.
The provider must document all applicable gaseous and liquid refill amounts and delivery information in the consumer's medical record.
(2) Modifier code QE shall be used and the medicaid maximum payment amount reduced by fifty per cent of the amount set forth in appendix DD to rule 5101:3-1-60 of the Administrative Code when the prescribed amount of oxygen is one liter per minute or less. If the QE modifier is used, the provider must document all applicable gaseous and liquid refill amounts and delivery information in the consumer's medical record.
(3) Modifier code QG shall be used and the medicaid maximum payment amount increased by fifty per cent of the amount set forth in appendix DD to rule 5101: 3-1-60 of the Administrative Code when:
(a) The prescribed amount of oxygen is greater than four liters per minute continuous and portable oxygen is not prescribed; and
(b) If the QG modifier is used, the provider must document all applicable gaseous and liquid refill amounts and delivery information in the consumer's medical record.
(4) Modifier code QF shall be used and the medicaid maximum payment amount increased by fifty per cent of the amount set forth in appendix DD to rule 5101: 3-1-60 of the Administrative Code when:
(a) The prescribed amount of oxygen is greater than four liters per minute continuous and portable oxygen is also prescribed; and
(b) If the QF modifier is used, the provider must document all applicable gaseous and liquid refill amounts and delivery information in the consumer's medical record.
(E) Payment for oxygen claims.
(1) The following codes are the only codes authorized to be utilized in an ICF-MR when seeking reimbursement for oxygen services rendered:
(a) E0441-Oxygen contents, stationary system, gaseous;
(b) E0442-Oxygen contents, stationary system, liquid;
(c) E1390-Oxygen concentrator, single port; and
(d) E1391-Oxygen concentrator, dual port.
(2) Code E1391 is used in situations in which two medicaid consumers are both using the same concentrator. In this situation, this code will only be billed for one of the consumers using the equipment. Both consumers must be using medicaid benefits in order for this code to be valid for reimbursement.
(3) Oxygen claims are paid on a per month basis. All claims must show billed charges for one month's service. Billed charges for gaseous or liquid oxygen as well as services provided by the use of an oxygen concentrator shall be no more than the provider's usual and customary charge for these services provided in the same setting. For consumers receiving gaseous or liquid oxygen, documentation of the amount of oxygen actually used each month (as determined from the documented refill amount and delivery information) must be maintained in the provider's file. For consumers receiving oxygen that is supplied by an oxygen concentrator, providers must keep the consumer's most current prescription on file to verify that continued oxygen services are warranted due to medical necessity.
(4) Documentation of the amount of oxygen used does not meet the requirements of this rule when such documentation is created or collected from sources other than the provider after the service has been billed.
(5) All equipment and supplies associated with oxygen administration to residents of an ICF-MR is reimbursable through the facility's cost report as set forth in Chapter 5101:3-3 of the Administrative Code. Therefore, the cost of reservoirs, stands/carts, regulators, humidifiers, cannulas, masks, and tubing must be billed to the facility.
(6) In an ICF-MR, rented oxygen systems, including portable units, are contained in the cost report of the facility in question and are not separately reimbursable. Purchased oxygen systems will be denied as noncovered.
(7) Payment for oxygen services provided to a consumer is inclusive of the following components:
(a) Set up and instructions;
(b) Transportation and/or delivery charges;
(c) Emergency services (to include the supply of backup oxygen supplies) or subsequent/interim visits;
(d) Maintenance and repairs to include any supplies or attachments that are integral to the operation of the oxygen system being supplied;
(e) Oxygen consumed (when applicable); and
(f) Equipment monitoring visits.
(8) When oxygen services are delivered from an oxygen concentrator, the oxygen concentrator will be serviced and maintained in accordance with the manufacturer's specifications, unless ordered otherwise by the prescriber. Service and maintenance records will be documented in the consumer's medical record or provider's file.
(9) All billing for oxygen services will stop immediately when a consumer fails to meet any of the criteria contained within this rule pertaining to the qualifications necessary for the administration of oxygen services.
(10) Except as otherwise provided, ODJFS reimburses medical suppliers at the lesser of billed charges or the medicaid maximum payment as set forth in appendix DD to rule 5101:3-1-60 of the Administrative Code. Providers must bill their usual and customary charge for services provided when compared to similar services provided in the same setting to consumers with payer sources other than medicaid.
Ohio Department of Job and Family Services
Certificate of Medical Necessity/Prescription
See Appendix at
R.C. 119.032 review dates: 08/13/2009 and 10/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02, 5111.021, 5111.262, 5111.20
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 1/1/80, 3/1/84, 5/1/90, 6/20/90 (Emer), 9/5/90, 2/17/91, 5/25/91, 4/1/92 (Emer), 7/1/92, 3/31/94, 1/1/95, 8/1/95, 8/1/98, 10/11/01, 11/1/07, 7/31/09 (Emer)