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Oxygen Therapy

Provider Administrative Policy

Policy Date
November 2008
Revised/November 2010
Provider Type(s)
All Providers  


Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.


Oxygen Therapy

Oxygen therapy requires prior authorization for True Blue HMO and Secure Blue PPO members and medical necessity review for Flexi Blue PFFS members.
Initial Certification
Blue Cross of Idaho requires receipt of a completed Certificate of Medical Necessity (CMN) within 30 days of the initial request. We will authorize services for two months to provide ample time to measure oxygen saturation levels.
We do not require a current CMN for recertification after the authorization has expired. However, an oxygen saturation level reading taken within 60 days of the recertification request, as well as proof of a physician’s prescription, is required.
Blue Cross of Idaho accepts oxygen saturation levels taken by a durable medical equipment supplier or oxygen saturation levels members obtain from their physician. Measure oxygen saturation levels on room air. 

In lieu of subcontracting to a provider who provides at home testing, refer the patient to their physician. We do not accept subcontractor claims for oxygen saturation levels. 

Blue Cross of Idaho approves oxygen equipment as a rental item only and we do not have a capped purchase price. This includes stationary and portable gaseous and liquid systems that contain oxygen. Specific member contract limitations and medical necessity determines coverage.

Exception:  E1353 and E1355 are purchase items only and total purchase price is under $300.  Post claim review may occur to determine medical necessity.

Oxygen Coding
Blue Cross of Idaho follows Healthcare Common Procedure Coding System (HCPCS) standards for quantity designations and code descriptions.

HCPCS codes for delivery systems include contents; it is not our intent to make additional allowances for contents when billed separately. The content codes E0441 – E0444 & S8120 – S8121 do not have a separate allowance when billed in conjunction with the delivery system codes E1390, E1391, E0439, or E0424.

If more than one unit is billed for E0424 – E0444, E1390 – E1392 or S8120 – S8121 the claim will decrease the allowance to the equivalent of one unit based on charge amount. These codes are only billable once per month, therefore, we will edit and reduce in allowance any claim lines with a quantity greater than one. For example, if code E0442 is billed for $145 with a quantity of 70, Blue Cross of Idaho will only allow payment of $2.07. We divide the total charge amount by 70. Since only one unit per month is allowable, we apply pricing for just one unit.

Please indicate “from” and “to” dates in box 24A as the same date even though they represent an entire month. Use the earliest service date to populate these fields. For example, claims for the entire month of January would show both “from” and “to” dates of 01/01/09-01/01/09.

When decreased or increased oxygen flow is required to treat a patient, only use modifiers QE, QF & QG on codes E0424, E0439, E1390 & E1391.

Policy History

Date Action Reason
November 2010 Revised NU modifier information added to oxygen accessories
October 2009 Revised Unit and Modifier information added

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