evekhm/cms_iom_500 huggingface dataset:
Article - Oxygen and Oxygen Equipment - Policy Article (A52514)
Months 61 and afterAt any time after the end of the 5-year reasonable useful lifetime for oxygen equipment, the beneficiary may elect to receive new equipment, thus beginning a new 36-month rental period.If the beneficiary elects not to receive new equipment after the end of the 5-year reasonable useful lifetime and if the supplier retains title to the equipment, all elements of the payment policy for months 37-60 remain in effect. There is no separate payment for accessories or repairs. If the beneficiary was using gaseous or liquid oxygen equipment during the 36th rental month, payment can continue to be made for oxygen contents.If the beneficiary elects not to receive new equipment after the end of the 5-year reasonable useful lifetime and if the supplier transfers title of the equipment to the beneficiary, accessories, maintenance, and repairs are statutorily non-covered by Medicare. Contents are separately payable for beneficiary-owned gaseous or liquid systems.If a beneficiary enters Medicare FFS with beneficiary-owned equipment, accessories, maintenance, and repairs are statutorily non-covered by Medicare. Contents are separately payable for beneficiary-owned gaseous or liquid systems.OXYGEN CONTENTS:Payment for stationary and portable contents is included in the fee schedule allowance for stationary equipment. No payment can be made for oxygen contents in a month in which payment is made for stationary equipment.If the beneficiary was using stationary gaseous or liquid oxygen equipment during the 36th rental month, payment for stationary contents (E0441 or E0442) begins when the rental period for the stationary equipment ends.If the beneficiary was using portable gaseous or liquid equipment during the 36th rental month ofstationaryequipment (gaseous, liquid, or concentrator), payment for portable contents (E0443, E0444 or E0447) begins when the rental period for thestationaryequipment ends. If the beneficiary began using portable gaseous or liquid equipment after starting on stationary equipment, payment for the portable equipment would continue until the end of the 36-month rental period for that equipment even though payment was also being made for the portable contents.
Article - Oxygen and Oxygen Equipment - Policy Article (A52514)
If the beneficiary was using both stationary and portable gaseous or portable equipment during the 36th rental month of stationary equipment, payment for both stationary contents (E0441 or E0442) and portable contents (E0443, E0444 or E0447) begins when the rental for the stationary equipment ends.If the beneficiary is using only portable gaseous or liquid equipment and not stationary equipment during months 1 through 36 of the portable equipment rental, payment for portable contents begins when the rental period for the portable equipment begins. If stationary equipment is subsequently added, separate payment for portable contents ends because payment for contents is included in the payment for stationary equipment.If the beneficiary was not using gaseous or liquid equipment (stationary or portable) in the 36th month, but was subsequently switched to gaseous or liquid oxygen based on a treating practitioner order, contents may be paid.If the beneficiary has a stationary concentrator, portable liquid equipment, and a stationary liquid tank to fill the portable cylinders, when payment for contents begins, payment will only be made for portable liquid contents.Suppliers must provide whatever quantity of oxygen contents are needed for a beneficiarys activities both inside and outside the home.A maximum of 3 months of oxygen contents may be delivered at any one time. (Refer to Billing Information section [below] for additional information concerning billing oxygen contents.)There is no difference in payment for oxygen contents for beneficiaries receiving more than 4 LPM or less than 1 LPM.No more than 1 unit of service (UOS) for stationary contents and/or 1 UOS for portable contents per month are billable.Refer to the Coverage Indications, Limitations and/or Medical Necessity section of the LCD for additional information about refills of oxygen contents.MAINTENANCE OF EQUIPMENT:Initial 36 monthsThere is no separate payment for maintenance and servicing (M&S).Months 37 through 60
Article - Oxygen and Oxygen Equipment - Policy Article (A52514)
MAINTENANCE OF EQUIPMENT:Initial 36 monthsThere is no separate payment for maintenance and servicing (M&S).Months 37 through 60If a beneficiary was using a stationary concentrator, portable concentrator, or trans-filling equipment during the 36th rental month, Medicare will pay for an M&S visit no more often than every 6 months, beginning no sooner than 6 months following the end of the rental period. If the equipment is covered under a warranty that covers labor related to routine/general maintenance and servicing (e.g., inspection, changing filters, cleaning, and calibration), payment for the first M&S visit can be no sooner than 6 months following the end of that warranty.A supplier must actually make a visit to bill the service. If multiple M&S visits are made during a 6 month period, only one will be paid.There is no M&S payment for gaseous or liquid equipment.Month 61 and afterIf the beneficiary elects not to replace a concentrator or trans-filling equipment and if the supplier retains title to the equipment, coverage for M&S is the same as in months 37-60.If the beneficiary elects not to replace a concentrator or trans-filling equipment and if the supplier transfers title to the beneficiary, M&S is statutorily non-covered.OXYGEN ACCESSORIES:Accessories, including but not limited to, trans-tracheal catheters (A4608), cannulas (A4615), tubing (A4616), mouthpieces (A4617), face tent (A4619), masks (A4620, A7525), oxygen conserving devices (A9900), oxygen tent (E0455), humidifiers (E0555), nebulizer for humidification (E0580), regulators (E1353), and stand/rack (E1355) are included in the allowance for rented oxygen equipment. The supplier must provide any accessory ordered by the treating practitioner. Accessories used with beneficiary-owned oxygen equipment will be denied as non-covered.RELOCATION and TRAVEL:Months 1 through 36
Article - Oxygen and Oxygen Equipment - Policy Article (A52514)
RELOCATION and TRAVEL:Months 1 through 36If the beneficiary relocates outside the suppliers service area (either short-term travel, extended temporary relocation, or permanent relocation), then for the remainder of the rental month for which it billed, the home supplier is required to provide the equipment and related items/service itself or make arrangements with a different supplier to provide the equipment, items, and services. For subsequent rental months that the beneficiary is outside the service area, the home supplier is encouraged to either provide the equipment and related items/services itself or assist the beneficiary in finding another supplier in the new location. The home supplier may not bill for or be reimbursed by Medicare if it is not providing oxygen equipment or has not made arrangements with a different supplier to provide the equipment on the anniversary billing date. Medicare will pay only one supplier to provide oxygen during any one-rental month.Months 37 through 60If the beneficiary relocates outside the suppliers service area (either short-term travel, extended temporary relocation, or permanent relocation), the home supplier is required to either provide the equipment and related items/services itself or make arrangements with a different supplier to provide the equipment and related items/services.MiscellaneousOxygen services furnished by an airline to a beneficiary are non-covered. Payment for oxygen furnished by an airline is the responsibility of the beneficiary and not the responsibility of the supplier.Medicare does not cover items or services provided/used outside the United States and its territories. The supplier is not required to provide or arrange for oxygen use in those situations.BREAK-IN-SERVICE:
Article - Oxygen and Oxygen Equipment - Policy Article (A52514)
Break-in-billing/Part B payment without break-in-medical necessityIf beneficiary enters hospital or SNF or joins Medicare HMO and continues to need/use oxygen, when beneficiary returns home or rejoins Medicare FFS, payment resumes where it left offBreak-in-medical necessity (break-in-need)If need/use of oxygen ends for less than 60 days plus the remainder of the rental month of discontinuation and then resumes, payment resumes where it left offDuring the 36-month rental period, if need/use of oxygen ends for more than 60 days plus the remainder of the rental month of discontinuation and new medical necessity is established, a new 36 month rental period would beginDuring months 37-60, if need/use of oxygen ends for more than 60 days plus the remainder of the rental month of discontinuation and new medical necessity is established, a new rental period does not begin. The supplier who provided the oxygen equipment during the 36th rental month must provide all necessary items and services for the duration of the reasonable useful lifetime.
Article - Oxygen and Oxygen Equipment - Policy Article (A52514)
MISCELLANEOUS:Only rented oxygen equipment is eligible for coverage. Purchased oxygen equipment is statutorily non-covered.Oximeters (E0445) and replacement probes (A4606) will be denied as non-covered because they are monitoring devices that provide information to the treating practitioner to assist in managing the beneficiarys treatment.Respiratory therapist services are non-covered under the DME benefit.REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter and Written Order Prior to Delivery List is availablehere.Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD, it will be eligible for coverage.POLICY SPECIFIC DOCUMENTATION REQUIREMENTSIn addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.DOCUMENTATION REQUIREMENTS FOR INITIAL CLAIMS FOR OXYGENDocumentation for initial coverage requires information in the medical record showing:Evidence of qualifying test results at the time of need; and,Evidence of an evaluation of the qualifying test results by a treating practitionerIn order to provide initial coverage for beneficiaries in Groups I, II and III, there must be evidence in the medical record documenting one of the following A-C criteria:
Article - Oxygen and Oxygen Equipment - Policy Article (A52514)
In order to provide initial coverage for beneficiaries in Groups I, II and III, there must be evidence in the medical record documenting one of the following A-C criteria:Asymptomatic, hypoxemic patient who meets criteria for Group I or II; or,A symptomatic, normoxemic patient with a medical condition that improves with oxygen therapy; or,For beneficiaries with concurrent Obstructive Sleep Apnea (OSA), the qualifying oxygen saturation test is performed following optimal treatment of the OSA as described in the Coverage Indications, Limitations and/or Medical Necessity.DOCUMENTATION FOR CONTINUED PAYMENT OF OXYGEN AFTER INITIAL COVERAGEIn order to continue payment of oxygen and oxygen equipment claims, there must be evidence in the medical record documenting:Group IWhile there is no formal requirement for re-evaluation and retesting, providers should ensure that once qualified for home oxygen therapy, the oxygen therapy and oxygen equipment remain reasonable and necessary pursuant to Social Security Act 1862 (a)(1)(A).Group IIEvaluation and documentation of a repeat qualifying blood gas test by the treating practitioner between the 61stand 90thdays after initiation of therapy pursuant to Social Security Act 1834(a)(5)(E); and,A new SWO by the treating practitioner.Group IIIEvaluation and documentation of a repeat, normoxemic, qualifying blood gas test by the treating practitioner between the 61stand 90thdays after initiation of therapy, pursuant to National Coverage Determination (NCD) 240.2 and Social Security Act 1834(a)(5)(E); and,A new SWO by the treating practitioner.
Article - Oxygen and Oxygen Equipment - Policy Article (A52514)
Reimbursement ends unless these continued payment and documentation requirements are met. At such time that these continued payment and documentation requirements are met, payment will resume at the month in the rental cycle where the rental was stopped. A new, initial rental cycle does not begin when the continued payment documentation requirements are met.REPAIRS:The supplier must maintain detailed records describing the need for and nature of all repairs including a detailed explanation of the justification for any component or part replaced as well as the labor time to restore the item to its functionality.REPLACEMENT EQUIPMENT:Claims for the initial rental month (and only the initial rental month) must have the RA modifier (Replacement of DME item) added to the HCPCS code for the equipment when there is replacement due to reasonable useful lifetime or replacement due to damage, theft, or loss.Claims for the initial rental month must include a narrative explanation of the reason why the equipment was replaced and supporting documentation must be maintained in the supplier's files.A treating practitioners order is needed to reaffirm the medical necessity of the item for replacement of an item.MODIFIERSGA, GY, GZ, KX, N1, N2 and N3 MODIFIERS:For oxygen claims covered by Medicare prior to April 1, 2023, suppliers may continue to use the KX modifier or may use the N-modifiers for claims with dates of service on or after April 1, 2023.For initial claims for oxygen or new 36-month oxygen rental periods with dates of service on or after April 1, 2023, suppliers must use the N1, N2 or N3 modifier as described below:N1 modifier only if all of the criteria in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD have been met for Group I beneficiaries.N2 modifier only if all of the criteria in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD have been met for Group II beneficiaries.N3 modifier only if all of the criteria in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD have been met for Group III beneficiaries.
Article - Oxygen and Oxygen Equipment - Policy Article (A52514)
For initial claims for oxygen or new 36-month oxygen rental periods with dates of service on or after April 1, 2023, submitted with the KX modifier will be rejected for invalid modifier.If all of the criteria in the Coverage Indications, Limitations and/or Medical Necessity section have not been met, the GA, GY or GZ modifier must be added to the code. When there is an expectation of a medical necessity denial, suppliers must enter GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN), a GZ modifier if they have not obtained a valid ABN, or a GY modifier if the item or service is statutorily excluded.Depending on the claim date of service described above, claim lines billed without a GA, GY, GZ, KX, N1, N2 or N3 modifier will be rejected as missing information.QA, QB, QE, QF, QG and QR MODIFIERS:42 CFR Section 414.226(e) stipulates:If prescribed flow rate is different for stationary versus portable, the flow rate for stationary is used.If prescribed flow rate is different for the patient at rest versus the patient with exercise, the flow rate at rest is used.If prescribed flow rate is different for nighttime versus daytime use, the flow rates are averaged.
Article - Oxygen and Oxygen Equipment - Policy Article (A52514)
QA: For scenarios where the beneficiary has different daytime and nighttime oxygen flow requirements. Used if the average documented flow requirement from a daytime at rest qualifying test and flow rate for nocturnal oxygen requirement (standard arithmetic rounding rules apply) is <1 LPM.QB: For scenarios where the beneficiary has different daytime and nighttime oxygen flow requirements. Used if the average documented flow requirement from a daytime at rest qualifying test and flow rate for nocturnal oxygen requirement (standard arithmetic rounding rules apply) is >4 LPM, and portable oxygen is prescribed.QE: Used if the documented flow requirement on an at rest qualifying test is <1 LPM.QF: Used if the documented flow requirement on an at rest qualifying test is >4 LPM, and portable oxygen is prescribed. DO NOT use a flow requirement from a with exercise qualifying test.QG: Used if the documented flow requirement on an at rest qualifying test is >4 LPM. DO NOT use a flow requirement from a with exercise qualifying test.QR: For scenarios where the beneficiary has different daytime and nighttime oxygen flow requirements. Used if the average documented flow requirement from a daytime at rest qualifying test and flow rate for nocturnal oxygen requirement (standard arithmetic rounding rules apply) is >4 LPM.For normoxemic patients, with non-respiratory conditions, Q-modifiers may be billed for medically necessary high flow rates, as defined in the Coverage Indications, Limitations and/or Medical Necessity section of the Oxygen and Oxygen Equipment LCD.CODING GUIDELINESThe appropriate modifier must be used if the prescribed flow rate is less than 1 LPM (QA or QE) or greater than 4 LPM (QG or QR).For claims with dates of service on or after 04/01/2018 the modifier QB or QF should be used in conjunction with claims submitted for stationary oxygen (codes E0424, E0439, E1390, or E1391) and portable oxygen (codes E0431, E0433, E0434, E1392, or K0738) when the prescribed amount of oxygen is greater than 4 liters per minute (LPM).
Article - Oxygen and Oxygen Equipment - Policy Article (A52514)
HCPCS code E1391 (Oxygen concentrator, dual delivery port) is used in situations in which two beneficiaries are both using the same concentrator. In this situation, this code should only be billed for one of the beneficiaries.HCPCS codes E1405 and E1406 describe oxygen and water vapor enriching systems with or without heated delivery respectively. These devices both extract oxygen from the surrounding air (similar to an oxygen concentrator) and add humidification. They require substantially higher oxygen flow rates in order to deliver the same concentration of oxygen as that achieved by standard oxygen delivery systems (for example, concentrators or liquid/gaseous systems). Since codes E1405 and E1406 require a higher flow rate but do not provide a benefit to the beneficiary in terms of the inspired concentration of oxygen, modifiers QB, QF, QG, and QR, which are appended to claim lines to indicate oxygen flow rates greater than 4 liters/minute, must not be used with codes E1405 and E1406.HCPCS code E1392 describes an oxygen concentrator which is designed to be portable, is capable of delivering 85% or greater oxygen concentration, and is capable of operating on either AC or DC (e.g., auto accessory outlet) power. Code E1392 includes the device itself, an integrated battery or beneficiary-replaceable batteries that are capable of providing at least 2 hours of remote portability at a minimum of 2 LPM equivalency, a battery charger, an AC power adapter, a DC power adapter, and a carry bag and/or cart. The combined weight of the concentrator and the battery/batteries capable of 2 hours of portability must be 20 pounds or less. If a concentrator meets all of these criteria and is also capable of functioning as a stationary concentrator, operating 24 hours per day, 7 days per week, the stationary concentrator code (E1390) is billed in addition to code E1392.
Article - Oxygen and Oxygen Equipment - Policy Article (A52514)
HCPCS code K0738 describes a feature of an oxygen concentrator that allows the beneficiary to fill portable gaseous oxygen cylinders from a stationary concentrator. This feature may be integrated into the stationary concentrator or be a separate component. When code K0738 is billed, code E0431 (portable gaseous oxygen system, rental) must not be used.HCPCS code E0433 describes a feature of an oxygen concentrator that allows the beneficiary to fill portable liquid oxygen cylinders from a stationary concentrator. This feature may be integrated into the stationary concentrator or be a separate component. When code E0433 is billed, code E0434 (portable liquid oxygen system, rental) must not be used.HCPCS code E1352 (OXYGEN ACCESSORY, FLOW REGULATOR CAPABLE OF POSITIVE INSPIRATORY PRESSURE) provides positive pressure inspiratory support for patients using oxygen. This product consists of multiple components - control unit, flow regulator, connecting hose and nasal interface (pillows). E1352 is an all-inclusive code for this product that includes all components.HCPCS code E0467 (HOME VENTILATOR, MULTI-FUNCTION RESPIRATORY DEVICE, ALSO PERFORMS ANY OR ALL OF THE ADDITIONAL FUNCTIONS OF OXYGEN CONCENTRATION, DRUG NEBULIZATION, ASPIRATION, AND COUGH STIMULATION, INCLUDES ALL ACCESSORIES, COMPONENTS AND SUPPLIES FOR ALL FUNCTIONS) describes a ventilator that integrates the function of multiple types of equipment into a single device. Code E0467 combines the function of a ventilator with all of the following: