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DME MAC Jurisdiction C Oxygen Denial Help Aid

Below are categories of denials associated with oxygen. To find additional explanations and key references from Medicare policy, follow these steps: (1) Select the documentation category; (2) Scroll down the list of denial explanations to find the denial reason(s) listed on your claim denial letter; and (3) Click on the corresponding denial explanation link (red letters) to expand the table to reveal the documentation requirement plus links to references providing additional information.

Documentation Type Denial Explanation Requirement Reference

CMN

The documentation does not include an initial Certificate of Medical Necessity.

An Initial, Recertification, or Revised CMN must be obtained and submitted with oxygen claims in situations described in the LCD. Circumstances that require a new initial CMN include when the first claim for home oxygen is submitted and when the equipment is replaced because reasonable useful lifetime of prior equipment has been reached or replacement is necessary due to irreparable damage, theft, or loss of the originally dispensed equipment.

A copy of the CMN must be maintained by the supplier and be available to a Medicare contractor upon request.

Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11446)

DME MAC Jurisdiction C Supplier Manual, Chapter 4PDF

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.3External PDF
CMN The Certificate of Medical Necessity is missing the treating physician's signature. A supplier must receive a signed CMN from the treating physician before they can submit a claim for payment to Medicare. A signed original, faxed photocopied, or electronic CMN must be maintained by the supplier and be available upon request.

DME MAC Jurisdiction C Supplier Manual, Chapter 4PDF

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.3External PDF
CMN The Certificate of Medical Necessity contains corrections/changes that do not comply with accepted record keeping principles. If there is a change made to any section of the CMN after the physician has signed the CMN, the physician must line through the error and initial and date the correction; or the supplier may choose to have the physician complete a new CMN.

DME MAC Jurisdiction C Supplier Manual, Chapter 4PDF

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.3Edternal PDF
CMN The initial date on the Certificate of Medical Necessity is after the date of service.

The initial date on a CMN should represent the specific date the physician gives as the start of the medical necessity. If the physician does not give a specific date, the initial date would be the date of the order.

The "Delivery Date/Date of Service” on the claim must not precede the "Initial Date” on the CMN.

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.3.1External PDF

DME MAC Jurisdiction C Supplier Manual, Chapter 4PDF
CMN The Certificate of Medical Necessity is missing the physician's signature date. The "Signature Date” is the date the physician signed and dated Section D of the CMN. DME MAC Jurisdiction C Supplier Manual, Chapter 4PDF
CMN The Certificate of Medical Necessity contains a physician's signature which does not comply with the Centers for Medicare & Medicaid Services signature requirements. Medicare requires a legible identifier for services provided/ordered. The method used shall be handwritten or an electronic signature in accordance with chapter 3, section 3.3.2.4 of the Program Integrity Manual. Signature and date stamps are not acceptable for use on CMNs and DIFs.

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4External PDF

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.3.1External PDF

DME MAC Jurisdiction C Supplier Manual, Chapter 3, Section 5

DME MAC Jurisdiction C Supplier Manual, Chapter 4PDF
CMN Section A of the Certificate of Medical Necessity is not properly completed. For oxygen equipment, the supplier must receive a signed CMN from the treating physician before they can submit a claim for payment to Medicare. Section A and C are completed by the supplier and Section B and D are completed by the physician.

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.3External PDF

DME MAC Jurisdiction C Supplier Manual, Chapter 4PDF
CMN The medical record documentation does not support the date of the blood gas study test referenced on the Initial Certificate of Medical Necessity. Medicare Contractors have the authority to request to verify the information on a CMN at any time. If the information contained either in the supplier's records or in the patient's medical record maintained by the ordering physician fails to substantiate the CMN, the service will be denied. The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.3.1External PDF
CMN The medical record documentation does not support the blood gas study value referenced on the Revised Certificate of Medical Necessity. Medicare Contractors have the authority to request to verify the information on a CMN at any time. If the information contained either in the supplier's records or in the patient's medical record maintained by the ordering physician fails to substantiate the CMN, the service will be denied. The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.3.1External PDF
CMN The Certificate of Medical Necessity is missing the beneficiary's name. For oxygen equipment, the supplier must receive a signed CMN from the treating physician before they can submit a claim for payment to Medicare. Section A and C are completed by the supplier and Section B and D are completed by the physician.

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.3External PDF

DME MAC Jurisdiction C Supplier Manual, Chapter 4PDF
CMN The Certificate of Medical Necessity is not applicable to this beneficiary. For oxygen equipment, the supplier must receive a signed CMN from the treating physician before they can submit a claim for payment to Medicare. Section A and C are completed by the supplier and Section B and D are completed by the physician.

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.3External PDF

DME MAC Jurisdiction C Supplier Manual, Chapter 4PDF
CMN Section B of the Certificate of Medical Necessity is not properly completed. For oxygen equipment, the supplier must receive a signed CMN from the treating physician before they can submit a claim for payment to Medicare. Section A and C are completed by the supplier and Section B and D are completed by the physician.

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.3External PDF

DME MAC Jurisdiction C Supplier Manual, Chapter 4PDF
CMN The Certificate of Medical Necessity acting as the written order was signed after the date of service and no dispensing order was submitted.

Suppliers must have an order from the treating physician before dispensing a DMEPOS item to a beneficiary. Except for items requiring a written order prior to delivery, suppliers may dispense a DMEPOS item based on a written, fax or verbal dispensing order from the treating physician.

Suppliers must maintain the preliminary written order or written documentation of the verbal order and this documentation must be available to Medicare contractors upon request.

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.2External PDF

DME MAC Jurisdiction C Supplier Manual, Chapter 3, Section 3PDF

Medical Review Frequently Asked Questions (FAQs) – Fall 2011
Medical Records No medical record documentation was received.

The documentation in the patient's medical record does not have to be routinely sent to the supplier or to a Medicare contractor. However, a Medicare contractor may request this information in selected cases. If the contractor does not receive the information when requested or if the information in the patient's medical record does not adequately support the medical necessity for the item, then on assigned claims the supplier is liable for the dollar amount involved unless a properly executed advance beneficiary notice (ABN) of possible denial has been obtained.

The patient's medical record is not limited to the physician's office records. It may include hospital, nursing home, or HHA records and records from other health care professionals. CMNs, DIFs, physician orders, supplier prepared statements and physician attestation statements are not medical records and, even if signed by the treating physician, cannot stand alone in support of medical necessity.

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.7External PDF

DME MAC Jurisdiction C Supplier Manual, Chapter 3, Section 4
Medical Records The medical record documentation is not authenticated (handwritten or electronic) by the author.

Medicare requires that healthcare providers ordering or documenting the medical necessity for items or services received by Medicare beneficiaries must be identifiable. This is generally accomplished through a handwritten or electronic signature (signature stamps are not acceptable); however, when the author of a record is unclear, document (s) must be authenticated before payment can be made.

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4

July 2010 Medical Review FAQs

Attestation Statement Form

CMS Signature Requirements

Medical Records The medical record documentation does not support the beneficiary was seen and evaluated by the treating physician within 30 days prior to the date of initial certification. Documentation for initial coverage requires evidence of an in-person visit with a treating physician done within 30 days before the initial date of service. Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11446)
Medical Records The medical record documentation does not support the treating physician has determined that the beneficiary has a severe lung disease or hypoxia related symptoms that might be expected to improve with oxygen therapy.

Conditions for Which Oxygen Therapy May Be Covered

  • A severe lung disease, such as chronic obstructive pulmonary disease, diffuse interstitial lung disease, cystic fibrosis, bronchiectasis, widespread pulmonary neoplasm, or
  • Hypoxia-related symptoms or findings that might be expected to improve with oxygen therapy. Examples of these symptoms and findings are pulmonary hypertension, recurring congestive heart failure due to chronic cor pulmonale, erythrocytosis, impairment of the cognitive process, nocturnal restlessness, and morning headache.

Conditions for Which Oxygen Therapy Is Not Covered

  • 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;
  • Breathlessness without cor pulmonale or evidence of hypoxemia. Although intermittent oxygen use is sometimes prescribed to relieve this condition, it is potentially harmful and psychologically addicting;
  • Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities. There is no evidence that increased PO2 improves the oxygenation of tissues with impaired circulation; or
Terminal illnesses that do not affect the lungs.

The CMS Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 240.2External PDF

Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11446)
Medical Records Medical records do not verify that the standard treatment regimen associated with the disease condition producing the hypoxia-related symptoms was tried or considered and deemed clinically ineffective. While there is no substitute for oxygen therapy, each patient must receive optimum therapy before long-term home oxygen therapy is ordered. Medical documentation must indicate that other forms of treatment (e.g., medical and physical therapy directed at secretions, bronchospasm and infection) have been tried, have not been sufficiently successful, and oxygen therapy is still required. The CMS Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 240.2External PDF
Medical Records The medical record documentation contains a qualifying saturation for Group II, however the medical records do not support the presence of any qualifying conditions.

Group II criteria include the presence of (a) an arterial PO 2 of 56-59 mm Hg or an arterial blood oxygen saturation of 89 percent at rest (awake), during sleep for at least 5 minutes, or during exercise (as described under Group I criteria in the LCD) and (b) any of the following:

  1. Dependent edema suggesting congestive heart failure, or
  2. 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
Erythrocythemia with a hematocrit greater than 56 percent.
Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11446)
Medical Records The medical record documentation contains a qualifying saturation for Group II, however the medical records do not support the presence of dependent edema suggesting congestive heart failure. The medical records must verify that the dependent edema is due to congestive heart failure. Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11446)
Medical Records The medical record documentation includes an overnight oximetry showing a decrease of more than 5 percent from baseline saturation for at least 5 minutes taken during sleep, however does not support symptoms or signs reasonably attributable to hypoxemia. An overnight oximetry showing a decrease of more than 5 percent from baseline satuation for at least 5 minutes is not sufficient alone to approve home oxygen coverage. Medical records must also document symptoms or signs reasonably attributable to hypoxemia. Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11446)
Medical Records The medical record documentation does not support a severe underlying lung disease.

Oxygen coverage is limited to beneficiaries with a severe lung disease or a condition that results in hypoxia-related symptoms. Furthermore, coverage is only available if the qualifying test reveals significant hypoxemia while the beneficiary is in the chronic stable state, i.e. not during a period of acute illness or an exacerbation of their underlying disease.

A qualifying test conducted within two days of discharge is deemed to be an acceptable substitute for the usual chronic stable state requirement. However, hypoxia related to a purely acute condition, like pneumonia, would not qualify for payment because pneumonia alone is not a chronic lung condition. Coverage criteria would only be met if, in addition to the pneumonia, the beneficiary had a chronic underlying lung disease or other condition that produced hypoxia.

The CMS Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 240.2External PDF

Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11446)

Medical Review Frequently Asked Questions (FAQs) – Summer 2012
Medical Records The physician's order, Certificate of Medical Necessity, supplier prepared statement nor a physician's attestation, by itself, provides sufficient documentation of medical necessity For any DMEPOS item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information should include the patient's diagnosis and other pertinent information including, but not limited to, duration of the patient's condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc. If an item requires a CMN or DIF, it is recommended that a copy of the completed CMN or DIF be kept in the patient's record. However, neither a physician's order nor a CMN nor a DIF nor a supplier prepared statement nor a physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier. There must be information in the patient's medical record that supports the medical necessity for the item and substantiates the answers on the CMN (if applicable) or DIF (if applicable) or information on a supplier prepared statement or physician attestation (if applicable).

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.7External PDF

Medical Records The medical record documentation does not clearly indicate the author of the amendment, correction or delayed entry.

When making review determinations, Medicare contractors will consider all submitted medical record entries with amendments, corrections or delayed entries as long as the entries comply with widely accepted Recordkeeping Principles. The contractors will not consider any entries that do no comply with the recordkeeping principles. For example, they will not consider undated or unsigned entries handwritten in the margin of a document. Instead, they will exclude these entries from consideration.

Regardless of whether a documentation submission originates from a paper record or an electronic health record, documents submitted to Medicare contractors containing amendments, corrections or addenda must:

  1. Clearly and permanently identify any amendment, correction or delayed entry as such, and
  2. Clearly indicate the date and author of any amendment, correction or delayed entry, and
Not delete but instead clearly identify all original content.
The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.5(B)
Medical Records The medical record documentation does not clearly indicate the date of the amendment, correction or delayed entry.
Medical Records The medical record documentation contains corrections/changes that do not comply with accepted record keeping principles.
Medical Records The medical record documentation does not clearly identify all original content of the amendment, correction or delayed entry.
Physician Order: Preliminary Dispensing Order

The detailed written order was signed after the date of service and no dispensing order was submitted.

Suppliers must have an order from the treating physician before dispensing a DMEPOS item to a beneficiary. Except for items requiring a written order prior to delivery, suppliers may dispense a DMEPOS item based on a written, fax or verbal dispensing order from the treating physician.

Suppliers must maintain the preliminary written order or written documentation of the verbal order and this documentation must be available to Medicare contractors upon request.

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.2External PDF

DME MAC Jurisdiction C Supplier Manual, Chapter 3, Section 3PDF

Medical Review Frequently Asked Questions (FAQs) – Fall 2011
Physician Order: Preliminary Dispensing Order

The imaged copy of the dispensing order is of poor quality and illegible.

It is the supplier's responsibility to assure that all Medicare documentation requirements are met and legible copies can be made available upon request.

Medical Review Frequently Asked Questions (FAQs) – December 2009

CGS Online Article: Faxing Tips – August 31, 2009
Physician Order: Preliminary Dispensing Order The dispensing order is missing a description of the item.

The dispensing order must include:
• A description of the item
• The beneficiary's name
• The name of the physician
• The date of the order and the start date, if the start date is different from the date of the order
• The physician's signature (written order) or supplier's signature (verbal order)

For the "date of the order” described above, use the date the supplier was contacted by the physician (for verbal orders) or the date entered by the physician (for written dispensing orders).

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.2External PDF

DME MAC Jurisdiction C Supplier Manual, Chapter 3, Section 3PDF
The dispensing order is missing the beneficiary's name.
The dispensing order is missing the prescribing physician's name.
The dispensing order is missing the date of the order and the start date, if start date is different from the date of the order.
The verbal dispensing order is missing the supplier's signature.
The written dispensing order is missing the physician's signature.
Physician Order: Detailed Written Order The documentation does not include a detailed written order.

Detailed written orders are required for all transactions involving DMEPOS. Detailed written orders may take the form of a photocopy, facsimile image, electronically maintained, or original "pen-and-ink" document.

Suppliers must maintain a copy of the detailed written order in the beneficiary's file and this documentation must be available to Medicare contractors upon request.

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.3

DME MAC Jurisdiction C Supplier Manual, Chapter 3, Section 3PDF
Physician Order: Detailed Written Order The detailed written order is missing the treating physician's signature. Medicare requires that healthcare providers ordering or documenting the medical necessity for items or services received by Medicare beneficiaries must be identifiable. If a signature assessment reveals that an order is missing a signature, the order will be disregarded.

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4

July 2010 Medical Review FAQs

Attestation Statement Form

CMS Signature Requirements

Physician Order: Detailed Written Order The detailed written order contains a physician's signature which does not comply with the Centers for Medicare & Medicaid Services signature requirements. A legible identifier is required to authenticate the author of all services provided/ordered. This identifier shall either be a handwritten or electronic signature.

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4

July 2010 Medical Review FAQs

Attestation Statement Form

CMS Signature Requirements

Physician Order: Detailed Written Order The detailed written order is missing the date the treating physician signed the order. Someone other than the physician may complete the detailed description of the item. However, the treating physician must review the detailed description and personally sign and date the order to indicate agreement. The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.3
Physician Order: Detailed Written Order Written order invalid due to use of a signature and/or date stamp. For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a handwritten or electronic signature. Stamped signatures are not acceptable. The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4
Physician Order: Detailed Written Order The detailed written order is missing the beneficiary's name.

An order for home oxygen must include all of the following elements:

  1. Beneficiary's name,
  2. Physician's name,
  3. Specific list of all items to be dispensed,
  4. Means of O2 delivery (if other than by nasal cannula),
  5. Oxygen flow rate,
  6. Estimate of the frequency or duration of use,
  7. The treating physician's signature,
  8. The date of the treating physician's signature, and
Start date (if different from signature date).

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.3

Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11446)

December 2009 Medical Review FAQs
The detailed written order is missing a detailed description of the item.
The detailed written order is missing the date of the order and the start date, if start date is different from the date of the order.
The written dispensing order is missing the treating physician's signature.
Physician Order: Detailed Written Order The detailed written order contains corrections/changes that do not comply with accepted record keeping principles. A legible identifier is required to authenticate the author of all services provided/ordered. This identifier shall either be a handwritten or electronic signature. The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.5
Physician Order: Detailed Written Order The detailed written order is signed by the physician after the claim was submitted Suppliers must have a detailed written order prior to submitting a claim. If the supplier does not have a faxed, photocopied, electronic or pen and ink signed detailed written order in their records before they submit a claim to Medicare (i.e., if there is no order or only a dispensing order), the claim will be denied.

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.3

DME MAC Jurisdiction C Supplier Manual, Chapter 3, Section 3PDF
Physician Order: Detailed Written Order The detailed written order is illegible. It is the supplier's responsibility to assure that all Medicare documentation requirements are met and legible copies can be made available upon request.

Medical Review Frequently Asked Questions (FAQs) – December 2009

CGS Online Article: Faxing Tips – August 31, 2009
The imaged copy of the detailed written order is of poor quality and illegible.
Physician Order: Detailed Written Order The detailed written order was written prior to Medicare eligibility.

Before submitting a claim to the DME MAC the supplier must have on file a dispensing order, the detailed written order, the CMN (if applicable), the DIF (if applicable), information from the treating physician concerning the patient's diagnosis, and any information required for the use of specific modifiers or attestation statements as defined in certain DME MAC policies…

Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare FFS program. When a beneficiary receiving a DMEPOS item from another payer becomes eligible for the Medicare FFS program, the beneficiary may continue to receive such items only if Medicare requirements are met for such DMEPOS items…

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.8External PDF

Physician Order: Detailed Written Order Section C of the Certificate of Medical Necessity acting as the detailed written order does not contain a detailed description of the item(s) ordered. The CMN can serve as the physician's detailed written order if the narrative description in section C is sufficiently detailed. This would include quantities needed and frequency of replacement for accessories and supplies. For items requiring both a CMN and a written order prior to delivery (seat lift mechanisms and TENS units) suppliers may utilize a completed and physician-signed CMN for this purpose. Otherwise, a separate order in addition to a subsequently completed and signed CMN is necessary.

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.3External PDF

DME MAC Jurisdiction C Supplier Manual, Chapter 3, Section 3PDF
Portable Equipment The documentation does not include a detailed written order prior to delivery for the item(s) specified in the Affordable Care Act 6407. The face-to-face and prescription provisions of the Affordable Care Act (ACA) 6407 apply to HCPCS codes E0424, E0431, E0433, E0434, E0439, E0441, E0442, E0443 and E0444. A dispensing order is not sufficient to provide these items. A Written Order Prior to Delivery (WOPD) is required. Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11446)
Proof of Delivery Records indicate the beneficiary received this equipment prior to Medicare Fee-for-Service eligibility. The documentation did not include a statement, signed and dated by the beneficiary, that the supplier has examined the item and attests to the fact that the item meets Medicare requirements.

Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare FFS program. When a beneficiary receiving a DMEPOS item from another payer becomes eligible for the Medicare FFS program, the beneficiary may continue to receive such items only if Medicare requirements are met for such DMEPOS items…

The proof of delivery serves as evidence that the beneficiary is already in possession of the item. The beneficiary's signature is required on the proof of delivery. A date of delivery must be noted by the supplier, beneficiary, or designee. The first day of the first rental month in which Medicare payments are made for the item serves as the start date of the reasonable useful lifetime and period of continuous use. The DME MAC shall consider the proof of delivery requirements met for this type of beneficiary by instructing the suppler to obtain a statement, signed and dated by the beneficiary (or beneficiary's designee), that the supplier has examined the item…

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.8External PDF

Proof of Delivery The documentation did not include proof of delivery for the item(s) billed. Suppliers are required to maintain proof of delivery documentation in their files for seven (7) years and this documentation must be available to Medicare contractors upon request.

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26External PDF

The CMS Pub. 100.08, Medicare Program Integrity Manual, Chapter 5, Section 5.8External PDF

DME MAC Jurisdiction C Supplier Manual, Chapter 3, Section 7External PDF
Proof of Delivery The proof of delivery is illegible. It is the supplier's responsibility to assure that all Medicare documentation requirements are met and legible copies can be made available upon request.

Medical Review Frequently Asked Questions (FAQs) – December 2009

CGS Online Article: Faxing Tips – August 31, 2009
Proof of Delivery The proof of delivery is missing the beneficiary's name.

Suppliers may deliver directly to the beneficiary or the designee. In this case, POD to a beneficiary must be a signed and dated delivery slip. The POD record must include:

  • Beneficiary's name
  • Delivery address
  • Sufficiently detailed description to identify the item(s) being delivered (e.g., brand name, serial number, narrative description)
  • Quantity delivered
  • Date delivered
  • Beneficiary (or designee) signature and date of signature
The date of signature on the delivery slip must be the date that the DMEPOS item was received by the beneficiary or designee.

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26External PDF

DME MAC Jurisdiction C Supplier Manual, Chapter 3, Section 7External PDF
The proof of delivery is missing the delivery address.
The proof of delivery does not contain a sufficiently detailed description of contents.
The proof of delivery is missing the quantity delivered.
The proof of delivery is missing the date delivered.
The proof of delivery is missing the beneficiary or authorized representative signature.
The proof of delivery contains a description of contents not consistent with the item billed.
Proof of Delivery The beneficiary signature date indicating proof of delivery is after the date of service.

In instances where the supplies are delivered directly by the supplier, the date the beneficiary received the DMEPOS supply must be the date of service on the claim.

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26External PDF

DME MAC Jurisdiction C Supplier Manual, Chapter 3, Section 7External PDF
The beneficiary signature date indicating proof of delivery is prior to the date of service.
Qualifying Blood Gas Study The medical record documentation does not include a blood gas study. For any DMEPOS item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered. If an item requires a CMN, it is recommended that a copy of the completed CMN be kept in the patient's record. However, neither a physician's order nor a CMN nor a supplier prepared statement nor a physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier. There must be information in the patient's medical record that supports the medical necessity for the item and substantiates the answers on the CMN.

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.7External PDF

Medical Review Frequently Asked Questions (FAQs) – March 2010
Qualifying Blood Gas Study The blood gas study reported is not corroborated in the medical record documentation. A prescription is not considered part of the medical record. ….neither a physician's order nor a CMN nor a DIF nor a supplier prepared statement nor a physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier. There must be information in the patient's medical record that supports the medical necessity for the item and substantiates the answers on the CMN (if applicable) or DIF (if applicable) or information on a supplier prepared statement or physician attestation (if applicable).

The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.7External PDF

Qualifying Blood Gas Study Beneficiary meets Group III criteria, therefore there is a rebuttable presumption of noncoverage. Group III includes beneficiaries with arterial PO 2 levels at or above 60 mm Hg or arterial blood oxygen saturations at or above 90 percent. For these beneficiaries there is a rebuttable presumption of noncoverage. Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11446)
Qualifying Blood Gas Study The medical record documentation does not support a valid blood gas study obtained at rest. Initial claims for oxygen therapy must also include the results of a blood gas study that has been ordered and evaluated by the attending physician. The CMS Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 240.2External PDF
Qualifying Blood Gas Study The medical record documentation does not support a valid blood gas study obtained during exercise. When oxygen is covered based on an oxygen study obtained during exercise, there must be documentation of three (3) 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 (to demonstrate the improvement of the hypoxemia) are required. All 3 tests must be performed within the same testing session. Only the testing during exercise without oxygen is used for qualification and reported on the CMN. The other two results do not have to be routinely submitted but must be available on request.

Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11446)

Medical Review Frequently Asked Questions (FAQs) – Fall 2011

Medical Review Frequently Asked Questions (FAQs) – March 2010
The blood gas study obtained during exercise does not include testing at rest without oxygen.
The blood gas study obtained during exercise does not include testing during exercise without oxygen.
The blood gas study obtained during exercise does not include testing during exercise with oxygen applied showing an improvement of hypoxemia.
Qualifying Blood Gas Study The medical record documentation does not indicate all three oximetry studies for exercise testing were performed in one session. When oxygen is covered based on an oxygen study obtained during exercise, there must be documentation of three (3) 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 (to demonstrate the improvement of the hypoxemia) are required. All 3 tests must be performed within the same testing session. Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11446)
Qualifying Blood Gas Study The medical record documentation does not support the blood gas study was the one obtained closest to, but no earlier than two days prior to discharge from an inpatient facility.

If the qualifying blood gas study is performed during an inpatient hospital stay, the reported test must be the one obtained closest to, but no earlier than 2 days prior to the hospital discharge date.

Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11446)
Qualifying Blood Gas Study The medical record documentation does not support the blood gas study was obtained while the beneficiary was in a chronic stable state.

For those patients whose initial oxygen prescription did not originate during a hospital stay, blood gas studies should be done while the patient is in the chronic stable state, i.e., not during a period of an acute illness or an exacerbation of their underlying disease.

The CMS Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 240.2External PDF

Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11446)
Qualifying Blood Gas Study The medical record documentation does not support that the obstructive sleep apnea was appropriately and sufficiently treated such that the beneficiary was in a chronic stable state prior to sleep study. All co-existing diseases or conditions that can cause hypoxia must be treated and the patient be in a chronic stable state before oxygen therapy is considered eligible for payment. In the case of OSA, it is required that the OSA be appropriately and sufficiently treated such that the patient is in the chronic stable state before oxygen saturation results obtained during sleep testing are considered qualifying for oxygen therapy.

Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11446)

Medical Review FAQs – Spring 2011
Qualifying Blood Gas Study The medical record documentation does not support the blood gas study was the most recent study obtained within 30 days prior to the initial date. Documentation for initial coverage of home oxygen requires evidence of qualifying test results done within 30 days before the initial date of service. Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11446)
Qualifying Blood Gas Study The medical record documentation does not support a valid blood gas study obtained during sleep. An arterial PO 2 at or below 55 mm Hg, or an arterial oxygen saturation at or below 88 percent, for at least 5 minutes taken during sleep for a beneficiary who demonstrates an arterial PO 2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89 percent while awake, or… Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11446)
Qualifying Blood Gas Study The medical record documentation does not include an overnight oximetry showing a decrease of more than 5 percent from baseline A decrease in arterial PO 2 more than 10 mm Hg, or a decrease in arterial oxygen saturation more than 5 percent from baseline saturation, for at least 5 minutes taken during sleep associated with symptoms (e.g., impairment of cognitive processes and [nocturnal restlessness or insomnia]) or signs (e.g., cor pulmonale, "P" pulmonale on EKG, documented pulmonary hypertension and erythrocytosis) reasonably attributable to hypoxemia, or… Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11446)
Qualifying Blood Gas Study The medical record documentation does not demonstrate a qualifying Group II oxygen saturation of 89 percent, for at least 5 minutes taken during sleep.

Group II criteria include the presence of

  • An arterial PO 2 of 56-59 mm Hg or an arterial blood oxygen saturation of 89 percent at rest (awake), during sleep for at least 5 minutes, or during exercise (as described under Group I criteria), and
  • Any of the following:
  1. Dependent edema suggesting congestive heart failure, or
  2. 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
Erythrocythemia with a hematocrit greater than 56 percent.
Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11446)
Qualifying Blood Gas Study The blood gas study value reported on the Certificate of Medical Necessity from the overnight oximetry is not the lowest value during the 5 minute qualifying period.

For patients who qualify for oxygen coverage based only on a sleep oximetry study, the oxygen saturation value reported in question 1b of the Oxygen CMN must be the lowest value (not related to artifact) during the 5 minute qualifying period reported on the sleep oximetry study.

If the saturation falls to 88% or below for less than 5 cumulative minutes during the test but does fall to 89% for at least 5 cumulative minutes during the test, then the lowest value during the qualifying period is 89% because the beneficiary meets group II, not group I coverage criteria.

Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11446)

Medical Review FAQs – Spring 2011
Qualifying Blood Gas Study The medical record documentation does not include an overnight oximetry testing of at least 2 hours. For the purpose of qualifying for home oxygen during sleep, there must be a minimum of 2 hours test time recorded for sleep oximetry. The result must reach a qualifying value otherwise the Group III presumption of noncoverage applies. Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11446)
Qualifying Blood Gas Study The medical record documentation does not support a qualifying oxygen saturation test during a titration polysomnographic study, for a beneficiary with obstructive sleep apnea. Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11446)
Qualifying Blood Gas Study The medical record documentation does not support the titration polysomnography study was conducted over a minimum of two hours.

For beneficiaries 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:

  1. The titration is conducted over a minimum of two (2) hours; and
  2. During titration:
    1. The AHI/RDI is reduced to less than or equal to an average of ten (10) events per hour; or
    2. If the initial AHI/RDI was less than an average of (10) events per hour, the titration demonstrates further reduction in the AHI/RDI; and
  3. Noctural oximetry conducted for the purpose for oxygen reimbursement qualification may only be permitted after optimal PAP settings have been determined and the beneficiary is using the PAP device at those settings; and
The nocturnal oximetry conducted during the PSG demonstrates an oxygen saturation less than or equal to 88% for 5 minutes total (which need not be continuous).
Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11446)
Qualifying Blood Gas Study During the polysomnography study titration the apnea-hypopnea index (AHI)/respiratory disturbance index (RDI) was not reduced to less than or equal to an average of ten events per hour; or if the AHI/RDI was less than an average of ten events per hour the titration did not demonstrate a further reduction in AHI/RDI.

For beneficiaries 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:

  1. The titration is conducted over a minimum of two (2) hours; and
  2. During titration:
    1. The AHI/RDI is reduced to less than or equal to an average of ten (10) events per hour; or
    2. If the initial AHI/RDI was less than an average of (10) events per hour, the titration demonstrates further reduction in the AHI/RDI; and
  3. Noctural oximetry conducted for the purpose for oxygen reimbursement qualification may only be permitted after optimal PAP settings have been determined and the beneficiary is using the PAP device at those settings; and
The nocturnal oximetry conducted during the PSG demonstrates an oxygen saturation less than or equal to 88% for 5 minutes total (which need not be continuous).
Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11446)
Qualifying Blood Gas Study The medical record documentation does not support the titration polysomnography study was conducted after optimal positive airway pressure (PAP) settings were determined and the beneficiary is using the PAP device at those settings.

For beneficiaries 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:

  1. The titration is conducted over a minimum of two (2) hours; and
  2. During titration:
    1. The AHI/RDI is reduced to less than or equal to an average of ten (10) events per hour; or
    2. If the initial AHI/RDI was less than an average of (10) events per hour, the titration demonstrates further reduction in the AHI/RDI; and
  3. Noctural oximetry conducted for the purpose for oxygen reimbursement qualification may only be permitted after optimal PAP settings have been determined and the beneficiary is using the PAP device at those settings; and
The nocturnal oximetry conducted during the PSG demonstrates an oxygen saturation less than or equal to 88% for 5 minutes total (which need not be continuous).
Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11446)
Qualifying Blood Gas Study The medical record documentation does not support the titration polysomnography study demonstrated an oxygen saturation less than or equal to 88% for five minutes total.

For beneficiaries 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:

  1. The titration is conducted over a minimum of two (2) hours; and
  2. During titration:
    1. The AHI/RDI is reduced to less than or equal to an average of ten (10) events per hour; or
    2. If the initial AHI/RDI was less than an average of (10) events per hour, the titration demonstrates further reduction in the AHI/RDI; and
  3. Noctural oximetry conducted for the purpose for oxygen reimbursement qualification may only be permitted after optimal PAP settings have been determined and the beneficiary is using the PAP device at those settings; and
The nocturnal oximetry conducted during the PSG demonstrates an oxygen saturation less than or equal to 88% for 5 minutes total (which need not be continuous).
Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11446)
Qualifying Blood Gas Study The medical record documentation does not indicate the blood gas study at rest and/or during exercise was performed in person by a physician or a qualified provider or supplier of laboratory services. The qualifying test must be performed by a provider who is qualified to bill Medicare for the test – i.e., a Part A provider, a laboratory, an Independent Diagnostic Testing Facility (IDTF), or a physician. A supplier is not considered a qualified provider or a qualified laboratory for purposes of this policy. Blood gas studies performed by a supplier are not acceptable. In addition, the qualifying blood gas study may not be paid for by any supplier. These prohibitions do not extend to blood gas studies performed by a hospital certified to do such tests. Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11446)
Replacement Equipment The documentation submitted does not support the beneficiary's equipment has reached its reasonable usable lifetime and does not support that it was lost, stolen, or irreparably damanged in a specific incident.

Identical or nearly identical equipment may be replaced in the cases of loss or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire, flood, etc.).

Replacement of equipment due to irreparable wear (deterioration sustained from day-to-day usage over time and a specific event cannot be identified) takes into consideration the reasonable, useful lifetime of the equipment.

Reasonable, useful lifetime is calculated from the date the equipment was delivered and in no case can it be less than 5 years. Replacement due to wear is not covered during the reasonable, useful lifetime of the equipment.

DME MAC Jurisdiction C Supplier Manual, Chapter 5, Section 9PDF

Medical Review Frequently Asked Questions (FAQs) – Summer 2011

Medicare Billing Requirements and Policies for Replacement of Oxygen Equipment and Oxygen Contents
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