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December 12, 2013

Qualifying for Medicare Oxygen

Medical oxygen is regulated by the FDA as a drug, and so like many other drugs it requires a prescription. So, if you need supplemental oxygen and you have Medicare insurance, all your doctor should have to do is write a prescription and the equipment will be delivered to your door, right? Well, not so fast… Perhaps in days gone by it was that simple, but today there is a process for qualifying. To add to the complexity, all steps must occur within 30 days.

Simply stated, we need to have documentation that proves to Medicare that your medical oxygen is absolutely necessary. This includes qualifying oxygen test results, chart notes from your doctor, and a specific Medicare form to be completed by your doctor’s office. To qualify for oxygen equipment and supplies, your doctor must document a severe lung disease or other condition that interferes with your ability to breathe, he must note that your condition might improve with the use of oxygen, your oxygen saturation levels need to fall within a certain range, and it must be shown that other alternative measures have been tried that were not helpful for you.

The first component of this documentation is qualifying oxygen testing, typically a pulse oximetry test. Pulse oximetry is a non-invasive measurement method of monitoring a patient’s oxygen saturation. A sensor is placed on a thin part of the patient’s body, usually a fingertip. It works by passing a beam of red and infrared light through a pulsating capillary bed. The ratio of red to infrared blood light transmitted gives a measure of the oxygen saturation of the blood. The oximeter works on the principle that the oxygenated blood is a brighter color of red than the deoxygenated blood, which is more blue-purple. First, the oximeter measures the sum of the intensity of both shades of red, representing the fractions of the blood with and without oxygen. The oximeter detects the pulse, and then subtracts the intensity of color detected when the pulse is absent. The remaining intensity of color represents only the oxygenated red blood. This is displayed on the electronic screen as a percentage of oxygen saturation in the blood.

To qualify for home equipment (not portable), testing is done overnight while you sleep. To qualify for portable oxygen equipment, daytime testing is needed. The first part of this test must be done on room air while you are at rest, or seated. Many times this is all that is needed. However if your oxygen saturation at rest is too high to qualify for supplemental oxygen, you will be asked to do a test on exertion (walking) to see if your saturation drops. This walking test is also done on room air. The final part of the test is done while you are on oxygen to prove that your oxygen levels improve with the addition of supplemental oxygen.

The next part of documentation that we need involves a patient visit, also known as a face to face evaluation. Medicare requires you to have a face-to-face visit with your doctor, so he cannot merely fax in an order without seeing you. This face-to-face can be a general office visit where oxygen is discussed along with other health issues, or it can be a visit specifically arranged to review your need for supplemental oxygen. The tangible result of this visit is the chart notes. Doctor visits result in chart notes, and the chart notes from that visit must document that you need and benefit from medical oxygen. There is a saying in the healthcare industry, “If it isn’t documented, it didn’t happen.” If you visited your doctor and discussed oxygen, but that discussion of oxygen was not documented in the chart notes, we have no way of proving to Medicare that you need it. Keep in mind that testing results alone are insufficient to qualify for Medicare oxygen, so when chart notes like this are received, the patient has to make yet another appointment with the doctor. To complicate matters, the oxygen testing and face-to-face visit with your doctor must be within a time span of 30 days.

The final part of the process is a medical form, specifically known as CMS 484 or a Certificate of Medical Necessity (CMN). This is a form that your doctor will fill out. Once Breath of Life has received this form from your doctor we can set up the oxygen equipment that he or she has prescribed.

This may seem an odd question, but does your doctor know that you use supplemental oxygen? If you have used supplemental oxygen and you have a new doctor, the new doctor may not be aware of it if he never prescribed it, he never sees you with it, and it has never been discussed in previous office visits. As a patient, it is your responsibility to tell your doctor about your oxygen, how often you use it, and how you benefit from it. This often becomes an issue when it is time to renew oxygen certification.

Your initial certification for Medicare oxygen is valid for one year, and then it must be recertified, and that renewal is good for four more years. New testing is not necessary for recertification, but a face-to-face appointment and new Medicare form are still needed. If you have a new doctor who is unaware of your need and use of supplemental oxygen, the doctor is not likely to sign documentation that is needed to recertify it.

Medicare will help cover 80% of the cost of home oxygen equipment and supplies after you have met the yearly deductible if you have a breathing condition that it will help to improve. Medicare payment for oxygen equipment and supplies is subject to the requirement that it is necessary and reasonable for treatment of an illness or injury and/or to improve the functioning of the patient. If you receive your Medicare through a Medicare Advantage Plan (such as an HMO or PPO), it is likely you will have to follow the plan’s steps for approval.

Qualification of Oxygen can vary depending on the test results or how the doctor writes the order; however, your supplier, Breath of Life will walk you through the process step by step. If you have any questions about your Medicare oxygen qualification, contact Breath of Life at 866-777-3380 or call Medicare at 1-800-MEDICARE (1-800-633-4227).