When you entered the home care field, you probably had images of providing care and comfort to those in need. Most of us never imagined that in order
by Kelly J. Riley, CRT, RCP

When you entered the home care field, you probably had images of
providing care and comfort to those in need. Most of us never
imagined that in order to assure access to care for those we serve,
we would need to be just as cognizant of words like
“transmittal,” “advisory opinion” and
“bulletin” as we are of the words
“concentrator,” “conserver” and

Although sifting through policy, transmittals and Office of
Inspector General opinions is not something we look forward to, it
must be done. And that information must then be disseminated to
those sending orders for the patient's care.

One important transmittal has made it easier for HME suppliers
and physicians to obtain oxygen-qualifying overnight oximetry test

CMS Transmittal 173, published in August 2005, allows the HME
supplier (or other shipping entity) to deliver a sealed,
tamper-proof oximeter to the patient's home on behalf of an
Independent Diagnostic Testing Facility. This process can only
happen after the patient's physician has ordered an overnight
oximetry test.

CMS is very clear that the physician — not the provider
— must request the test. However, providers are permitted to
contact the physician regarding the need for testing in certain
circumstances, for example: when recertification is due, when
testing is required due to change in insurance, when the initial
test was invalid, i.e., not done with patient in a chronic stable
state, or within two days of discharge from a hospital.

Providers who have patients enrolled in disease management-type
programs may continue to communicate with the physician in regard
to findings on ordered clinical assessments.

A recent OIG advisory opinion strongly states that HME companies
may not perform free pre-screening oximetry tests for patients. It
is also prohibited for a company to set up oxygen for free while
waiting for a qualifying test.

In the event that the patient must be set up on oxygen without
the qualifying test, the provider must give the patient an Advanced
Beneficiary Notice advising that the services provided will not be
covered because they do not meet the payment coverage rules set by

The policy issued by CMS states that the beneficiary may
self-administer home- based overnight oximetry tests under the
direction of the IDTF. Because the beneficiary self-administers the
test, the IDTF must provide clear, written instructions on proper
operation of the equipment, and provide a mechanism for the
beneficiary to address questions to the IDTF.

The IDTF will send results only to the ordering physician. In
the event that the HME provider is currently furnishing oxygen, or
has a release that is compliant with HIPAA privacy standards signed
by the beneficiary or his/her representative, the provider may
obtain a copy of the test results directly from the IDTF. It is
important that the provider obtain copies of test results and keep
them in the patient file, whether the tests are completed by an
IDTF, a physician's office or a hospital.

According to guidelines issued by CMS, testing that is done by a
home health agency does not constitute a valid qualifying test. The
only exception would be an uncommon situation where the HHA is also
a qualified lab or IDTF.

Testing done while the patient is in a skilled nursing facility
is considered valid as long as the facility has maintained its
qualifications for laboratory services.

Getting appropriate medical care paid for should be of a primary
interest to all. Patients who worry about having coverage for
services are more inclined to refuse those services. Often, this
results in a decline in health status and increased costs to the
health care system as a whole.

It is important that those of us who provide care take the time
to care about those pesky things like transmittal notices, advisory
opinions and bulletins.


John W. Salyer, “Neonatal and Pediatric Pulse
Oximetry,” Respiratory Care, August 2003

Jeffrey S. Baird, Esq., “Oxygen Rules
Clarification: What the Provider Can and Cannot Do,” The MED
Group E-Conference, November 2006

Kevin M. Fussel, MD, et al, “Assessing Need for
Long-Term Oxygen Therapy: A Comparison of Conventional Evaluation
and Measures of Ambulatory Oximetry Monitoring,”
Respiratory Care, February 2003

Charlotte Bell, MD, “Understanding Contemporary Pulse
Oximetry,” Clinical Window Web Journal, June 2005

Neil R. MacIntyre, MD, FAARC, “Long-Term Oxygen
Therapy: Conference Summary,” Respiratory Care,
February 2000

Qualifying Patients for Home Ambulatory Oxygen

Evaluation for long-term oxygen therapy involves a resting Spo2
or Pao2, and the lowest Spo2 during some form of exertion, to
identify patients who suffer substantial desaturation during
activities of daily living. For payment coverage under Medicare's
policy, exercise or exertion is not defined.

Morrison et al studied 20 COPD patients receiving LTOT using 24
hours of continuous oximetry. The study found that 11 patients who
did not have resting hypoxia (Spo2 >90%) spent an average of 22
percent of the 24-hour period with Spo2 <90%, demonstrating that
some patients with normal resting Spo2 spend a substantial amount
of time hypoxemic!

Recognizing that certain COPD patients are often hypoxic while
exercising or simply performing activities of daily living, many
physicians choose portable oxygen therapy as part of the plan of
care. CMS supports this decision by providing payment as long as
certain criteria are met.

The primary issue, according to the Oxygen Medical Policy
published by CMS, is not the extent of the exercise performed but
whether the patient is also tested during exercise with oxygen.
Medicare wants to see evidence that the hypoxemia is improved with
oxygen applied.

The Oxygen Medical Policy, in fact, requires documentation of
three oxygen studies in the patient's medical record: testing at
rest without oxygen, testing during exercise without oxygen and
testing during exercise with oxygen applied.

Only the results from the test during exercise without oxygen
are entered on the CMN. The other results must be in the patient's
medical records, preferably of both the oxygen supplier and
physician, and must be available to the Medicare Administrative
Contractor (the DME MAC) on request.

Documentation and physician oversight of the three oxygen
studies is good medicine, as it provides a baseline for ongoing
evaluation of the patient with pulmonary disease.

With more than 25 years of respiratory experience in both
institutional and home care settings, Kelly J. Riley, CRT, RCP, is
director, National Respiratory Network, for The MED Group, Lubbock,
Texas. Previously, she served as COO for At Home Medical (formerly
Via Christi at Home) in Ponca City, Okla. Riley can be reached by
e-mail at kriley@medgroup.com or by phone at 580/762-3500.