Just Breathe

I have received more calls and emails than ever from the provider community about capped rental misunderstandings. Of course, questions about oxygen account for the largest number of the calls now that the regs have changed and patients will not assume ownership of their oxygen equipment after 36 months of rental.

Let’s understand the capped rental model and know how to implement these changes within our corporate environment as well as understanding coverage guidelines.

Oxygen policies for coverage have not changed in coverage guidelines for reimbursement. Oxygen is covered for patients with hypoxia-related symptoms or severe lung disease. They either have to be a Group I or Group II patient to qualify.

A Group I patient has a PO2 of 55 mm hg or below, or an O2 saturation of 88 percent or below. A Group II patient has a PO2 of 56-59 mm hg, or an O2 saturation of 89 percent with the answer to one of Questions 7, 8 or 9 on the oxygen CMN being “yes.” These questions ask if the patient has a hematocrit greater than 56 percent; or if the patient has dependent edema due to congestive heart failure; or cor pulmonale or pulmonary hypertension.

You must also have audit procedures in place to ensure you have a copy of the physician progress notes, labs and documentation of one of these existing in the patient’s medical records.

For all oxygen patients in pre-payment or post-payment audits, you are required to have a copy of the PO2 or O2 saturation in the patient’s file to ensure the tests documented in Question 1 on the CMN are the actual test results on the report from the independent diagnostic testing facility or physician’s office. Make sure if the PO2 is 55.5 mm hg that it is rounded to a 56 mm hg, which makes the beneficiary a Group II patient.

For Group I patients, you need an initial CMN for coverage. The test results must be within 30 days prior to the initial delivery date. Be sure your intake staff is educated in this matter.

One year from the initial date, you are required to obtain a one-year recertification CMN. If the length of need is 99 months (lifetime), then the patient does not have to be retested for coverage. But if the patient has been retested in the past year, then the most recent test result must be recoded on the CMN.

The patient must be seen by the treating physician within 90 days of the one-year recert date, and this must be documented in the patient’s medical records. If your patient is not seen within 90 days prior to the recert date, then the patient’s billing recert date will change to the date the patient is seen by the treating physician.

For Group II patients, you will have your initial CMN with stated tests results with the additional documentation. Then between the 61st and 90th day, the patient will be rested and now will qualify as a Group I patient to continue home oxygen therapy. Then you will have your one-year recert as a Group I patient as stated above.

Be sure your staff is following up and these patients are being retested in a timely manner. I see a lot of accounts receivable being written off because these patients have not been followed up.

If you have a patient who has been tested and prescribed a conserving device, be sure you add the “QH” modifier on the claim showing you have a written prescription for the conserving device or that it is included in Section C of the CMN. Medicare does not reimburse for conserving devices.

At the end of 36 months of capped rental payments, the oxygen equipment is capped out, but it will now remain the property of the provider. CMS has yet to release the payment structure for maintenance, refills for portables and amounts and repairs for oxygen equipment. Stay tuned for the requirements on this major change, hopefully to be announced soon since these patients begin capping out in January 2009.

Train your staff accordingly and understand that with the 9.5 percent reimbursement cuts in January … and deductibles … and losing the revenue from your long-term oxygen patients, you must collect your co-pays, work aging A/R and denials and bill it right the first time. We can do it together!

Jane Bunch is president/CEO of Jane’s Healthcare Consulting based in Marietta, Ga. A reimbursement specialist, Bunch delivers educational seminars, helps develop corporate compliance plans and serves as a consultant for fraud and abuse cases. She can be reached at 770/366-0644 or by email at [email protected].