Meet Medical Necessity for Oxygen

For many providers, oxygen is the lifeblood of their revenue cycle. But Medicare is making it increasingly difficult to keep the oxygen cash flow in a positive state.

We have CERT, pre-pay audits, Additional Documentation Requests (ADRs) and also more complicated redeterminations and reconsiderations to validate a patient’s medical need. 

Remember the good old days when a Certificate of Medical Necessity (CMN) sufficed as proof of medical necessity? Unfortunately, our new reality involves chart note documentation from referral sources.

Providers should have the following documentation to prove medical necessity of claims: 

• A copy of the most recent Certificate of Medical Necessity (CMN) dated before service started
• The treating physician’s detailed written order for DMEPOS items. CMN can serve as a detailed written order if it is sufficiently completed.
• If the Date of Service (DOS) is before the signature date on the Detailed Written Order (DWO), proof of a dispensing order must be submitted.
• Copy of the beneficiary’s most recent arterial blood gas PO2 and/or oxygen saturation test value reported on the CMN
• Documentation of a physician office visit before the initial date of service; the physician’s office visit must be within 30 days of the initial CMN date or within 90 days of the recertification CMN date.
• Valid Proof of Delivery
• Contemporaneous—within the past six months—chart notes proving on-going need for oxygen after recertification

When responding to audits and documentation requests, many providers fall short on chart notes regarding the physician office visit before the initial date of service. This needs to occur within 30 days of the initial CMN date or within 90 days of the recertification CMN date.

Also pay attention to visit notes from the physician because many providers are being denied on medical necessity redeterminations and reconsiderations because they lack the 30- and 90-day visit notes proving a patient was assessed and requires oxygen.

In a recent oxygen prepayment audit completed by NHIC Corp., the Jurisdiction A DME MAC, 56.3 percent of the denied claims had problems because of visit notes.  Problems included:

• 26.9 percent of the denied claims were missing treating physician visits—within 30 days of initial CMN, or initial issue of oxygen.
• 26.5 percent of denied claims were missing treating physician visits both for 30 days within the initial CMN and 90 days within the recertification CMN (initial issue of oxygen).
• 2.9 percent of denied claims were missing treating physician visits—within 90 days of the recertification CMN (initial issue of oxygen).

Staff members should be aware when working an audit, ADR or medical necessity appeal that the physician visit notes and the testing reports must meet criteria of the local coverage decision (LCD).

For any audit, suppliers will be sent a documentation request for information. The requested information must be returned within 30 days from the date of the letter to avoid claim denials.

For redeterminations and reconsiderations ensure that the visit notes are available as the DME MACs are looking for those when reviewing the medical necessity denial appeals.

To see if your referral sources can provide you with the notes you need regarding their oxygen visits, give them the “test.” Pick your top five to ten referral sources and request the notes.

No. 1:  Do they respond in a timeframe which you can meet the 30-day response time to an audit?  No. 2: Do the notes meet the intent of the LCD regarding the oxygen visit requirements?

If your referral sources do not pass the test, education is the way to chart compliant notes.