(Medicare Claims Processing Manual)

130.4 - Billing for Certain Customized Items (Rev. 1, 10- 01-03) A3-3629, B3- 4107.8   Due to their unique nature (custom fabrication, etc.), certain customized DME cannot be grouped together for profiling purposes.  Claims for customized items that do not have specific HCPCS codes are coded as E1399 (miscellaneous DME).  This includes circu mstances where an item that has a HCPCS code is modified to the extent that neither the original terminology nor the terminology of another HCPCS code accurately describes the modified item.   Suppliers and providers other than HHAs bill the A/B MAC (B) or DME MAC.  HHAs bill their A/B MAC (HHH), using revenue code 0 292 along with the HCPCS.   130.5 - Billing for Capped Rental Items (Other Items of DME)  (Rev. 1, 10- 01-03) A3-3629, B3- 4107.8   These are DME items, other than oxygen and oxygen equipment, not covered by the above categories.  Suppliers and providers other than HHAs bill the DME MAC.  HHAs bill the A/B MACs (HHH).     130.6 - Billing for Oxygen and Oxygen Equipment  (Rev.  3895, Issued: 10- 27-17, Effective: 04 -01-18, Implementation: 04-  02-18) The following instructions apply to all claims from providers and suppliers to whom payment may be made for oxygen.  The chart in 130.6.1 indicates what is payable under which situation. A. Monthly Billing  Fee schedule payments for stationary oxygen system rentals are all inclusive and represent a monthly allowance per beneficiary.  Accordingly, a supplier must bill on a monthly basis for stationary oxygen equipment and contents furnished during a rental month. A portable equipment add- on is also payable when portable oxygen is prescribed and it is determined to be medically necessary in accordance with Medicare coverage requirements.  The portable add- on must be claimed in order to be paid.  (See 30.6.)  B. HCPCS Codes  The HCPCS codes must be used to report the service.  One month of service equals one unit. C. Use of Payment Modifiers and Revenue Codes for Payment Adjustments  The monthly payment amount for stationary oxygen is subject to adjustment depending on the amount of oxygen prescribed (liters per minute (LPM)), and whether or not portable oxygen is also prescribed.  (See 30.6.)  HHAs billing the A/B MAC (HHH) for stationary equipment, supplies, or contents, which are not eligible for payment adjustment, bill under revenue code 0601.  Claims must indicate the appropriate HCPCS modifier described below, if applicable.   If the prescribed amount of oxygen is less than 1 LPM, suppliers use the modifier "QE"; HHAs use revenue code 0602.  The monthly payment amount for stationary oxygen is reduced by 50 percent.   If the prescribed amount of oxygen is greater than 4 LPM, suppliers use the modifier "QG"; HHAs use revenue code 0603.  The monthly payment amount for stationary oxygen is increased by 50 percent.    If the prescribed amount of oxygen exceeds 4 LPM and portable oxygen is prescribed, suppliers use the modifier "QF"; HHAs use revenue code 0604.  The monthly payment for stationary oxygen is increased by the higher of 50 percent of the monthly stationary oxygen payment amount, or, the fee schedule amount for the portable oxygen add- on.  (A separate monthly payment is not allowed for the portable equipment.) Effective April 1, 2017, the modifier QF must be used with both the stationary and portable oxygen equipment codes.     Effective April 1, 2017, portable oxygen QF modifier fee schedule amounts will be added to the DMEPOS fee schedule file.  The portable oxygen QF fee schedule amounts will represent the higher of 1) 50 percent of the monthly stationary oxygen payment am ount or 2) the fee schedule amount for the portable oxygen add -on.  There are three claims processing scenarios:  Scenario 1  A claim for stationary oxygen equipment is submitted with the QG modifier. The history is reviewed and it is discovered that portable oxygen equipment was billed AND paid within the last 30 days prior to the stationary oxygen equipments date of service. Since we have already paid the portable add -on, we cant pay the volume adjustment add- on, therefore billing with QG modifier is inappropriate and the claim should be returned as unprocessable.  Scenario 2  A claim for stationary oxygen equipment is submitted with the QG modifier and within 30 days, a claim for portable oxygen equipment is received. In this case we have already paid the volume add- on so the portable equipment add on is returned as unprocessable.   Scenario 3  A claim for stationary oxygen equipment is submitted with the QG modifier AND the portable oxygen equipment comes in with the same date of service. In this case EVERYTHING is returned as unprocessable due to the incorrect use of the modifier a nd neither is valid.  NOTE: All these claims are being returned as unprocessable since there is no way for Medicare to know whether the first claim submitted was billed incorrectly or if the subsequent claim was billed incorrectly.   Contractors shall use the following messages for claims that are returned as unprocessable:  Group Code: CO (Contractual Obligation)  CARC 4 -  The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.  RARC MA130 -  Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable.  Please submit a new claim with the complete/correct information.   The following three new pricing modifiers are added to the HCPCS file effective April 1, 2018:  QA PRESCRIBED AMOUNTS OF STATIONARY OXYGEN FOR DAYTIME USE WHILE AT REST AND NIGHTTIME USE DIFFER AND THE AVERAGE OF THE TWO AMOUNTS IS LESS THAN 1 LITER PER MINUTE (LPM)   QB PRESCRIBED AMOUNTS OF STATIONARY OXYGEN FOR DAYTIME USE WHILE AT REST AND NIGHTTIME USE DIFFER AND THE AVERAGE OF THE TWO AMOUNTS EXCEEDS 4 LITERS PER MINUTE (LPM) AND PORTABLE OXYGEN IS PRESCRIBED   QR PRESCRIBED AMOUNTS OF STATIONARY OXYGEN FOR DAYTIME USE WHILE AT REST AND NIGHTTIME USE DIFFER AND THE AVERAGE OF THE TWO AMOUNTS IS GREATER THAN 4 LITERS PER MINUTE (LPM)   Additionally, the existing QE, QF, and QG modifiers are revised to clarify that the prescribed flow rate at rest is used in accordance with regulations at 42 CFR 414.226(e)(3). This section instructs that if the prescribed flow rate is different for the patient at rest than for the patient at exercise, the flow rate for the patient at rest is used. Effective April 1, 2018, the modifiers are revised to read:   QE PRESCRIBED AMOUNT OF STATIONARY OXYGEN WHILE AT REST IS LESS THAN 1 LITER PER MINUTE (LPM)   QF PRESCRIBED AMOUNT OF STATIONARY OXYGEN WHILE AT REST EXCEEDS 4 LITERS PER MINUTE (LPM) AND PORTABLE OXYGEN IS PRESCRIBED   QG PRESCRIBED AMOUNT OF STATIONARY OXYGEN WHILE AT REST IS GREATER THAN 4 LITERS PER MINUTE (LPM)   Beginning April 1, 2018, claims for monthly oxygen volume adjustments must indicate the appropriate HCPCS modifier described below as applicable. Oxygen fee schedule amounts are adjusted as follows:   If the prescribed amount of oxygen is less than 1 LPM, suppliers use either of the following modifiers with the stationary oxygen HCPCS code:    The modifier QE PRESCRIBED AMOUNT OF STATIONARY OXYGEN WHILE AT REST IS LESS THAN 1 LITER PER MINUTE (LPM); HHAs use revenue code 0602. The monthly payment amount for stationary oxygen is reduced by 50 percent.    The modifier QA PRESCRIBED AMOUNTS OF STATIONARY OXYGEN FOR DAYTIME USE WHILE AT REST AND NIGHTIME USE DIFFER AND THE AVERAGE OF THE TWO AMOUNTS IS LESS THAN 1 LITER PER MINUTE (LPM); The monthly payment amount for stationary oxygen is reduced by 50 perc ent. This modifier is used when the prescribed flow rate is different for nighttime use and daytime use and the average of the two flow rates is used in determining the volume adjustment.  If the prescribed amount of oxygen is greater than 4 LPM, suppliers use either of the following modifiers with the stationary oxygen HCPCS code:    The modifier QG PRESCRIBED AMOUNT OF STATIONARY OXYGEN WHILE AT REST IS GREATER THAN 4 LITERS PER MINUTE (LPM); HHAs use revenue code 0603. The monthly payment amount for stationary oxygen is increased by 50 percent.    The modifier QR PRESCRIBED AMOUNTS OF STATIONARY OXYGEN FOR DAYTIME USE WHILE AT REST AND NIGHTIME USE DIFFER AND THE AVERAGE OF THE TWO AMOUNTS IS GREATER THAN 4 LITERS PER MINUTE (LPM); HHAs use revenue code 0603. The monthly payment amount for stationary oxygen is increased by 50 percent.   If the prescribed amount of oxygen is greater than 4 LPM and portable oxygen is prescribed, suppliers use either of the following modifiers with both the stationary and portable oxygen HCPCS code:    The modifier QF PRESCRIBED AMOUNT OF STATIONAY OXYGEN WHILE AT REST EXCEEDS 4 LITERS PER MINUTE (LPM) AND PORTABLE OXYGEN IS PRESCRIBED; HHAs use revenue code 0604. If the prescribed flow rate differs between stationary and portable oxygen equipment, the flow rate for the stationary equipment is used. The monthly payment for stationary oxygen is increased by the higher of 50 percent of the monthly stationary oxygen payment amount, or the fee schedule amount for the portable oxygen add- on. A separate monthly payment is not allowed for the portable equipment. Effective April 1, 2017, the modifier QF must be used with both the stationary and portable oxygen equipment codes.    The modifier QB PRESCRIBED AMOUNTS OF STATIONARY OXYGEN FOR DAYTIME USE WHILE AT REST AND NIGHTTIME USE DIFFER AND THE AVERAGE OF THE TWO AMOUNTS EXCEEDS 4 LITERS PER MINUTE (LPM) AND PORTABLE OXYGEN IS PRESCRIBED; HHAs use revenue code 0604. If the pres cribed flow rate differs between stationary and portable oxygen equipment, the flow rate for the stationary equipment is used. The monthly payment for stationary oxygen is increased by the higher of 50 percent of the monthly stationary payment amount, or t he fee schedule amount for the portable oxygen add- on. A separate monthly payment is not allowed for the portable equipment. Effective April 1, 2018, the modifier Q?? must be used with both the stationary and portable oxygen equipment codes. The stationa ry and portable oxygen equipment QB fee schedule amounts will be added to the DMEPOS fee schedule file effective 4/1/2018.   The stationary oxygen QF and QB fee schedule amounts on the DMEPOS fee schedule file represent 100 percent of the stationary oxygen allowed fee schedule amount. The portable oxygen equipment add- on QF and QB fee schedule amount on the file by state represent the higher of:   1. 50 percent of the monthly stationary oxygen payment amount (codes E0424, E0439, E1390 or E1391); or   2. The fee schedule amount for the portable oxygen add- on (codes E0431, E0433, E0434, E1392 or K0738).  D. Conserving Device Modifier  The HHA's and suppliers must indicate if an oxygen conserving device is being used with an oxygen delivery system by using HCPCS modifier QH.  E. DME MACs Only  For all States that have licensure/certification requirements for the provision of oxygen and/or oxygen related products, DME MACs shall process claims for oxygen and oxygen related products only when an oxygen specialty code is assigned to the DMEPOS supplier by the NSC and is forwarded to the DME MACs from the NSC. This specialty shall be licensed and/or certified by the State when applicable.  This specialty shall bill for Medicare -covered services and/or products when State law permits such entity to furnish oxygen and/or oxygen related products.