Oxygen and Oxygen Equipment - Policy Article - Effective October 2015

Revision Effective Date: 04/01/2023
CODING GUIDELINES:
Removed: Coding and billing information pertaining to multifunction ventilators coded E0467
CODING VERIFICATION REVIEW:
Removed: Direction for HCPCS Code E0467 from section


05/16/2024: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 04/01/2023
CODING INFORMATION:
Added: "For all claims submitted with the N3 modifier.” to Group 1 Paragraph for ICD-10 Codes that DO NOT Support Medical Necessity
Added: ICD-10 codes J96.01, J96.11, J96.21, J96.91, R09.02 to Group 1 ICD-10-CM Codes that DO NOT Support Medical Necessity


03/21/2024: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 04/01/2023
MODIFIERS:
Added: Q-modifier billing instructions for normoxemic patients


04/20/2023: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 04/01/2023
DOCUMENTATION FOR CONTINUED PAYMENT OF OXYGEN AFTER INITIAL COVERAGE:
Revised: Documentation requirements for Group II and Group III to
remove re-evaluation and specify documentation of testing requirements (effective 09/27/2021)
MODIFIERS:
Added: N1, N2 and N3 modifier instructions
Revised: Direction regarding the use of the KX modifier on or after April 1, 2023


02/23/2023: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2023
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: Reference to Social Security Act §1834(a)(5)(E)
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: References to chronic stable state (effective 09/27/2021)
Revised: Documentation requirements to align with
information in the Coverage Indications, Limitations, and/or Medical Necessity section of the related Oxygen and Oxygen Equipment LCD (effective 09/27/2021)
Removed:
”LONG TERM OXYGEN THERAPY TRIALS (LTOT)” section and related information
 (effective 09/27/2021)
Removed: "
CLUSTER HEADACHES” section and related information

(effective 09/27/2021)
REPLACEMENT EQUIPMENT:
Removed: References to "Recertification" and "Certification of Medical Necessity"
CERTIFICATE OF MEDICAL NECESSITY (CMN):
Removed:
Section and related information
CODING GUIDELINES:
Removed: Clinical trial information for cluster headaches
ICD-10-CM CODES THAT SUPPORT MEDICAL NECESSITY:
Removed: Group 1 Paragraph information

Removed: ICD-10-CM codes from Group 1 Codes
Removed: Group 2 Paragraph information
Removed: ICD-10-CM code from Group 2 Codes
ICD-10-CM CODES THAT DO NOT SUPPORT MEDICAL NECESSITY:
Removed: Group 1 Paragraph
information


11/17/2022: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 08/02/2020
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 FED. REG VOL 217):
Removed: “The link will be located here once it is available.”
Added: “The required Face-to-Face Encounter and Written Order Prior to Delivery List is available here.” with a hyperlink to the list


04/14/2022: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 08/02/2020
CODING GUIDELINES:
Moved: E1405 and E1406 coding verification review (CVR) language to coding verification review section
Revised: Coding instructions for multifunction ventilators (E0467) (Effective 01/01/2019)
CODING VERIFICATION REVIEW:
Added: Section header and PDAC CVR information
Added: CVR requirement for products coded E1405, E1406 and E0467


11/11/2021: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 08/02/2020
CODING GUIDELINES:
Revised: Guidance for billing HCPCS code E0467 (Effective April 3, 2020)


08/13/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 08/02/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: “physician” to “treating practitioner”
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PERSUANT TO 42 CFR 410.38(g):
Removed: Section removed
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217):
Added: Section and related information based on Final Rule 1713
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Revised: “physician” to “treating practitioner”
CERTIFICATE OF MEDICAL NECESSITY (CMN):
Revised: “physician” to “treating practitioner”
Revised: “detailed written order” to “standard written order”
Removed: Outdated CMN Form number
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Covered” updated to “ICD-10 Codes that Support Medical Necessity”
ICD-10 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Not Covered” updated to “ICD-10 Codes that DO NOT Support Medical Necessity”


06/18/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2019
 CODING GUIDELINES:
Revised: E0467 Coding Guidelines to include custom fabricated oral appliances
Added: E0447, E1405, and E1406 to HCPCS codes included in E0467


04/04/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision History Effective Date: 01/01/2019
 NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
 Added: E0447 to Oxygen Content guidelines
 CODING GUIDELINES:
 Added: E0467 Coding Guidelines
 Revised: E1405 and E1406 Coding Guidelines
ICD-10 CODES THAT ARE COVERED:
 Added: All diagnosis codes formerly listed in the LCD
ICD-10 CODES THAT ARE NOT COVERED:
 Added: Notation excluding all unlisted diagnosis codes from coverage


02/14/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision History Effective Date: 08/01/2018
CERTIFICATE OF MEDICAL NECESSITY (CMN):
Removed: Flow rate instructions when answering CMN question 5
MODIFIERS:
 Added: GA, GY, GZ, and KX modifier requirement instructions
 Added: “Q” modifier instructions


06/07/2018: At this time 21st Century Cures Act applies to new and revised LCDs that restrict coverage, which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision History Effective Date: 04/01/2018
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES
Oxygen Equipment: Initial 36 months
Added: "the appropriate modifiers (QB or QF) must be used." in paragraph regarding flow rate greater than 4 LPM and also meets requirements for portable oxygen
Added: 42 CFR 410.38(g) language, previously in POLICY SPECIFIC DOCUMENTATION REQUIREMENTS section
CERTIFICATE OF MEDICAL NECESSITY
Added: Flow rate guidelines for beneficiaries who require differing day and night rates
CODING GUIDELINES
Revised: Flow rate modifiers for beneficiaries who require differing day and night rates
Revised: Coding guidelines for E1405 and E1406 to indicate that high flow rate modifiers (QB, QF, QG or QR) must not be used with these two HCPCS codes.


04/19/2018: At this time 21st Century Cures Act applies to new and revised LCDs that restrict coverage, which require comment and notice. This revision is to an  article that is not a local coverage determination.

Revision History Effective Date: 01/01/2018
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES
Oxygen Equipment: Initial 36 months
 Added: "the appropriate modifiers (QB or QF) must be used." in paragraph regarding flow rate greater than 4 LPM and also meets requirements for portable oxygen
Added: 42 CFR 410.38(g) language, previously in POLICY SPECIFIC DOCUMENTATION REQUIREMENTS section
CERTIFICATE OF MEDICAL NECESSITY
Added: Flow rate guidelines for beneficiaries who require differing day and night rates
CODING GUIDELINES
Revised: Flow rate modifiers for beneficiaries who require differing day and night rates
Revised: Coding guidelines for E1405 and E1406 to indicate that high flow rate modifiers (QB, QF, QG or QR) must not be used with these two HCPCS codes.


04/19/2018: At this time 21st Century Cures Act applies to new and revised LCDs that restrict coverage, which require comment and notice. This revision is to an  article that is not a local coverage determination.

Revision Effective Date: 01/01/2017
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: NCD 240.2, Long Term Oxygen Therapy Trails, Cluster Headaches, 42 CFR 410.38(g), Repair, Replacement and CMN requirements
CODING GUIDELINES:
Effective 04/01/2017, modifier QF may be used with portable systems or oxygen.
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements Language Article

Effective July 1, 2016 oversight for DME MAC Articles is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the Articles.

Revision Effective Date: 10/31/2014
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Removed: “When required by state law” from ACA new prescription requirements
Revised: Face-to-Face Requirements for treating practitioner