Or. Admin. Code § 410-122-0203

Current through Register Vol. 63, No. 11, November 1, 2024

Section 410-122-0203 - Oxygen and Oxygen Equipment

(1) Indications and limitations of coverage and medical appropriateness: The Division may cover home oxygen therapy services. Refer to Table 122-0203-1 and the following guidelines:

(a) For children under age 21 when the treating practitioner has determined oxygen services to be medically appropriate; or

(b) For adults age 21 years of age and older who are fully dual-eligible clients (Medicare clients who are also eligible for Medicaid/Oregon Health Plan (OHP); See definition in General Rules, OAR 410-120-0000), the Division may cover oxygen services as follows:

(A) If Medicare paid on the claim for the oxygen equipment, the Division may provide reimbursement;

(B) If Medicare denied payment on the claim for the oxygen equipment, the Division shall not provide reimbursement in accordance with Medicare rules and regulations;

(C) Refer to the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Supplemental Information for additional details on Medicare's reimbursement limitation of 36 monthly rental payments;

(c) For adults 21 years of age and older who are not eligible for Medicare (only eligible for Medicaid/OHP), PA is required and all of the following conditions must be met:

(A) The treating practitioner has ordered and evaluated the results of a qualifying blood gas study performed at the time of need; and

(B) The client's blood gas study meets the criteria stated below; and

(C) The qualifying blood gas study was performed by a treating practitioner or by a qualified provider or supplier of laboratory services; and

(D) The provision of oxygen and oxygen equipment shall improve the client's condition.

(d) Group I criteria include any of the following:

(A) An arterial partial pressure of oxygen (PO2) at or below 55 mm Hg or an arterial oxygen saturation (e.g. peripheral pulse oximetry reading) at or below 88 percent taken at rest (awake) while breathing room air; or

(B) An arterial PO2 at or below 55 mm Hg, or an arterial oxygen saturation (e.g. peripheral pulse oximetry reading) at or below 88 percent, taken during sleep for a client who demonstrates an arterial PO2 at or above 56 mm Hg or an arterial oxygen saturation (e.g. peripheral pulse oximetry) at or above 89 percent while awake. In this instance, oxygen and oxygen equipment is only necessary during sleep; or

(C) A decrease in arterial PO2 more than 10 mm Hg, or a decrease in arterial oxygen saturation (e.g. peripheral pulse oximetry reading) more than 5 percent from baseline saturation, taken during sleep and associated with symptoms of hypoxemia such as impairment of cognitive processes and nocturnal restlessness or insomnia (not all-inclusive).In this instance, oxygen and oxygen equipment is only necessary during sleep; or

(D) An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation (e.g. peripheral pulse oximetry reading) at or below 88 percent, taken during exercise for a client who demonstrates an arterial PO2 at or above 56 mm Hg or an arterial oxygen saturation (e.g. peripheral pulse oximetry reading) at or above 89 percent during the day while at rest. In this instance, portable oxygen and oxygen equipment is only necessary while awake and during exercise;

(e) Group II criteria include any of the following:

(A) An arterial PO2 of 56-59 mm Hg or an arterial blood oxygen saturation of 89 percent; and any of the following:

(i) Dependent edema suggesting congestive heart failure; or

(ii) 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

(iii) Erythrocythemia with a hematocrit greater than 56 percent;

(f) Group III criteria:

(A) Initial coverage of home oxygen therapy and oxygen equipment is necessary for clients in Group III if all of the following conditions are met:

(i) Absence of hypoxemia defined in Group I and Group II above, and

(ii) A covered medical condition with distinct physiologic, cognitive, and/or functional symptoms documented in high-quality, peer-reviewed literature to be improved by oxygen therapy;

(g) For all the sleep oximetry criteria, the five minutes does not have to be continuous;

(h) 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;

(i) If an ABG test at rest/awake is nonqualifying, but an exercise or sleep oximetry test on the same day is qualifying, the oximetry test result shall determine coverage;

(j) Oxygen therapy and related services, equipment or supplies are not considered medically appropriate or medically necessary for any of the following:

(A) 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;

(B) Dyspnea without cor pulmonale or evidence of hypoxemia;

(C) 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 PO2 shall improve the oxygenation of tissues with impaired circulation;

(D) Terminal illnesses that do not affect the ability to breathe;

(E) Emergency or stand-by oxygen systems for clients who are not regularly using oxygensince these services are precautionary and not therapeutic in nature;

(F) Topical hyperbaric oxygen chambers (A4575);

(G) When furnished by an airline (responsibility of the client);

(H) When provided/used outside the United States and its territories.

(2) Testing Specifications:

(a) The term blood gas study in this policy refers to both arterial blood gas (ABG) studies and pulse oximetry:

(A) An ABG is the direct measurement of the PO2 on a sample of arterial blood. The PO2 is reported as mm Hg.

(B) An oximetry test is the indirect measurement of arterial oxygen saturation (e.g. peripheral pulse oximetry reading) using a sensor on the ear or finger. The saturation is reported as a percent;

(C) An overnight oximetry is a 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;

(b) 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;

(c) All oxygen qualification testing must be performed by a qualified practitioner or other medical professional qualified to conduct oximetry:

(A) A DMEPOS provider is not considered a qualified provider or a qualified laboratory for purposes of this policy;

(B) Division shall not accept blood gas studies either performed or paid for by a DMEPOS provider;

(C) This prohibition does not extend to blood gas studies performed by a hospital certified to do such tests;

(d) When oxygen is covered based on an oximetry study obtained during exercise, there must be documentation of three oximetry studies performed within the same testing session in the client's medical record:

(A) Testing at rest without oxygen;

(B) Testing during exercise without oxygen; and

(C) Testing during exercise with oxygen applied, to demonstrate the improvement of the hypoxemia;

(e) All three tests must be performed in person by a treating practitioner or other medical professional qualified to conduct exercise oximetry testing;

(f) Only the qualifying test value (i.e., testing during exercise without oxygen) is used for qualification. All three (3) tests must be available upon request by the Division;

(g) The qualifying blood gas study may be performed while the client is on oxygen as long as the reported blood gas values meet the Group I or Group II criteria.

(3) Obstructive Sleep Apnea (OSA), Polysomnography and Home Sleep Tests:

(a) Home oxygen therapy and oxygen equipment with a PAP device is covered when criteria for both Oxygen and Oxygen Equipment and Positive Airway Pressure (PAP) devices for the treatment of Obstructive Sleep Apnea are met; and

(b) For clients with OSA, it is required that the OSA be appropriately and sufficiently treated before oxygen saturation results obtained during sleep testing are considered qualifying for oxygen therapy and oxygen equipment. This means that the OSA must be sufficiently treated such that the underlying condition resulting in hypoxemia is unmasked. This must be demonstrated before the oxygen saturation results are obtained during polysomnography are considered qualifying for oxygen therapy and oxygen equipment; and

(c) For clients 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:

(A) The titration is conducted over a minimum of two (2) hours; and

(B) During titration:

(i) The AHI/RDI is reduced to less than or equal to an average of ten (10) events per hour; or

(ii) 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

(C) Nocturnal oximetry conducted for the purpose of oxygen therapy qualification may only be performed after optimal PAP settings have been determined and the client is using the PAP device at those settings; and

(D) The nocturnal oximetry conducted during the PSG demonstrates an oxygen saturation of less than or equal to 88 percent;

(d) Overnight oximetry performed as part of home sleep testing or as part of any other home testing is not considered eligible to be used for qualification for reimbursement of home oxygen and oxygen equipment.

(4) Portable Oxygen Systems:

(a) A portable oxygen system may be covered if the client is mobile within the home for Groups I and II, 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 is not covered;

(b) If coverage criteria are met, a portable oxygen system is usually separately payable in addition to the stationary system. See exception in (6) below;

(c) If a portable oxygen system is covered, the DMEPOS provider must provide whatever quantity of oxygen the client uses; the reimbursement is the same, regardless of the quantity of oxygen dispensed.

(5) Liter flow greater than 4 LPM:

(a) If initial oxygen coverage criteria for Group 1, II, and III have been met, the Division will pay a higher allowance for a stationary system for a flow rate of greater than 4 LPM only when:

(A) Basic oxygen coverage criteria have been met; and

(B) A blood gas study performed while the client is on 4 LPM meets Group I or II criteria;

(b) Payment is limited to the standard fee schedule allowance if a flow rate greater than 4 LPM is billed and the coverage criteria for the higher allowance are not met.

(6) Documentation Requirements: The DMEPOS provider shall maintain and provide record of the face-to-face encounter and written order/prescription in addition to the qualifying documentation which supports conditions of coverage and testing requirements as specified in this rule are met;

(a) The written order for home oxygen must be completed, signed, and dated by the treating practitioner, not the DMEPOS provider, prior to delivery. The DMEPOS provider may use a written confirmation of other details of the oxygen order, or the treating practitioner can enter the other details directly, such as the means of oxygen delivery (cannula, mask, etc.) and the specifics of varying oxygen flow rates and/or non-continuous use of oxygen. There must be a treating practitioner's signed and dated order for each item billed. Items billed before a signed and dated order has been received by the DMEPOS provider must be submitted with an EY modifier added to each affected Healthcare Common Procedure Coding System (HCPCS) code;

(b) The following special instructions apply to replacement equipment:

(A) Initial date should be the date that the replacement equipment is initially needed. This is generally understood to be the date of delivery of the oxygen equipment;

(B) A treating practitioner's order is needed to reaffirm the medical necessity of the item for replacement of an item;

(C) 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;

(D) 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 DMEPOS provider's files;

(c) In the following situations, a new order must be obtained and kept on file by the DMEPOS provider; however, a repeat blood gas study are required:

(A) Prescribed maximum flow rate changes but remains within one of the following:

(i) Less than 1 LPM;

(ii) 1-4 LPM;

(iii) Greater than 4 LPM;

(B) Change from one type of stationary system to another (i.e., concentrator, liquid, gaseous);

(C) Change from one type of portable system to another (i.e., gaseous or liquid tanks, portable concentrator, transfilling system).

(7) Oxygen contents:

(a) The Division allowance for rented oxygen systems includes oxygen contents necessary for one month;

(b) Stationary oxygen contents (E0441, E0442) are separately payable only when the coverage criteria for home oxygen have been met and they are used with a client-owned stationary gaseous or liquid system respectively;

(c) Portable contents (E0443, E0444) are separately payable only when the coverage criteria for home oxygen have been met and:

(A) The client owns a concentrator and rents or owns a portable system; or

(B) The client rents or owns a portable system and has no stationary system (concentrator, gaseous, or liquid);

(C) If the criteria for separate payment of contents are met, they are separately payable regardless of the date that the stationary or portable system was purchased;

(d) Refer to Table 122-0203-2 for oxygen contents that may be reimbursable for dual-eligible clients.

(8) Oxygen accessory items:

(a) The allowance for rented systems includes, but is not limited to, the following accessories:

(A) Transtracheal catheters (A4608);

(B) Cannulas (A4615);

(C) Tubing (A4616);

(D) Mouthpieces (A4617);

(E) Face tent (A4619);

(F) Masks (A4620, A7525);

(G) Oxygen tent (E0455);

(H) Humidifiers (E0550, E0555, E0560);

(I) Nebulizer for humidification (E0580);

(J) Regulators (E1353);

(K) Stand/rack (E1355);

(b) The DMEPOS provider must provide any accessory ordered by the practitioner;

(c) Accessories are not separately payable.

(9) Billing for miscellaneous oxygen items:

(a) Only rented oxygen systems (E0424, E0431, E0434, E0439, E1390RR, E1405 RR, E1406RR, E1392RR) are considered for coverage;

(b) For gaseous or liquid oxygen systems or contents, report one unit of service for one month rental. Do not report in cubic feet or pounds;

(c) Use the appropriate modifier if the prescribed flow rate is less than 1 LPM (QE) or greater than 4 LPM (QF or QG). Division only accepts these modifiers with stationary gaseous (E0424) or liquid (E0439) systems or with an oxygen concentrator (E1390, E1391). Do not use these modifiers with codes for portable systems or oxygen contents;

(d) Use Code E1391 (oxygen concentrator, dual delivery port) in situations in which two clients are both using the same concentrator. In this situation, this code must only be requested for one of the clients;

(e) For E1405 and E1406 (oxygen and water vapor enriching systems), products must be coded as published by the Pricing, Data Analysis and Coding (PDAC) Contractor by the Centers for Medicare and Medicaid Services;(f) Code E1392 describes a portable oxygen concentrator system. Use E1392 when billing the Division for the portable equipment add-on fee for clients using lightweight oxygen concentrators that can function as both the client's stationary equipment and portable equipment. A portable concentrator:

(A) Weighs less than 10 pounds;

(B) Is capable of delivering 85 percent or greater oxygen concentration; and

(C) Is capable of providing at least two hours of remote portability at a 2 LPM order equivalency;

(g) Contact the PDAC for guidance on the correct coding of these items.

(10) Table 122-0203-1, Oxygen and Oxygen Equipment.

(11) Table 122-0203-2, Oxygen Contents.

Or. Admin. Code § 410-122-0203

OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 4-2001, f. 3-30-01, cert. ef. 4-1-01; OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 47-2002, f. & cert. ef. 10-1-02; OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03; OMAP 76-2003, f. & cert. ef. 10-1-03; OMAP 25-2004, f. & cert. ef. 4-1-04; OMAP 44-2004, f. & cert. ef. 7-1-04; OMAP 11-2005, f. 3-9-05, cert. ef. 4-1-05; OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07; DMAP 15-2007, f. 12-5-07, cert. ef. 1-1-08; DMAP 37-2008, f. 12-11-08, cert. ef. 1-1-09; DMAP 40-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10; DMAP 101-2023, amend filed 12/29/2023, effective 1/1/2024; DMAP 3-2024, minor correction filed 01/04/2024, effective 1/4/2024

Tables referenced are available from the agency.

To view attachments referenced in rule text, click here to view rule.

Statutory/Other Authority: ORS 413.042 & 414.065

Statutes/Other Implemented: ORS 414.065