Description
Documentation will be reviewed to determine if Home Oxygen meets coverage criteria and is medically reasonable and necessary.
Affected Code(s)
E1390, E0431
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(5) - Payment for oxygen and oxygen equipment; §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services
3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B
4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions
8. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements.
9. 42 CFR §414.65- Payment for Telehealth Services
10. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery
11. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare
12. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies; §100.2.3- Evidence of Medical Necessity for Oxygen
13. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations
14. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.26- Supplier Proof of Delivery Documentation Requirements
15. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1- Home Use of DME, §5.2- Rules Concerning Orders; §5.2.1- Physician Orders; §5.2.2- Verbal and Preliminary Written Orders; §5.2.3- Detailed Written Orders; §5.2.4- Written Orders Prior to Delivery; §5.2.5- Face-to-Face Encounter Requirements; §5.2.5.1- Face-to-Face Encounter Conducted by the Physician; §5.2.5.2- Face-to-Face Encounter Conducted by a Nurse Practitioner, Physician Assistant or Clinical Nurse Specialist; §5.2.6- Date and Timing Requirements; §5.2.7- Requirement of New Orders; §5.2.8- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.5- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.6- Physician Assistant Rules Concerning Orders and CMNs; §5.7- Documentation in the Patient's Medical Record; §5.8- Supplier Documentation; §5.9 Evidence of Medical Necessity; §5.9.1- evidence of medical Necessity for the Oxygen Claims (*Historical, for claims with Dates of Service Prior to 01/01/2020)
16. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; §5.11- Evidence of Medical Necessity; §5.11.1- Evidence of Medical Necessity for the Oxygen Claims
17. Medicare National Coverage Determination Manual, Chapter 1, Part 4, §240.2- Home Use of Oxygen
18. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC Local Coverage Determination L33797: Oxygen and Oxygen Equipment; Effective 10/01/2015; Revised 08/02/2020
19. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC Local Coverage Article A52514: Oxygen and Oxygen Equipment- Policy Article; Effective 10/01/2015; Revised 8/02/2020
20. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 04/06/2020