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PAP209

Oxygen and Oxygen Equipment


Provider Administrative Policy

Section
Claims Submission
Policy Date
December 2006
Status/Date
Revised/March 2013
Provider Type(s)
All Providers  

Disclaimer

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.

Policy

Oxygen and Oxygen Equipment

Background

Beginning April 1,2013 Blue Cross of Idaho processes oxygen equipment related claims according to CMS guidelines as established in the linked Noridian documentation. The following is a summary of billing procedures and definitions that direct the provider in the process of billing oxygen related claims. For information not defined directly in this administrative policy please refer to the Noridian documentation. These topics may include modality changes, travel oxygen, break in billing/need, replacement equipment, maintenance/repair, exceptions, etc.

https://www.noridianmedicare.com/dme/coverage/resources/oxygen_and_oxygen_equipment_billing_manual.pdf%3f

Suggested Intake Form

To determine whether same or similar items have previously been provided and to verify all coverage criteria is met; suppliers should follow a thorough intake process. Asking for the right information up front will prevent denials in the future. Noridian has a Suggested Intake Form to help begin this process, which may include the following:

  • Patient's correct Health Insurance Claim Number (HCN)
  • Whether the patient has employer insurance or is enrolleed in a Health Maintenance Organization (HMO)
  • If the patient currently has or had an identical or similar item in the past
  • When the patient received the items and whether or not the items have been returned
  • Where the patient will use the item

Reasonable Useful Lifetime

The reasonable useful lifetime for stationary or portable oxygen equipment begins as soon as the oxygen equipment is delivered to the beneficiary and continues until he or she uses the stationary or portable oxygen equipment on a continuous basis for five years. Computation of the reasonable useful lifetime is not based on the age of the equipment.

  • If there is a change in oxygen equipment modalities, e.g., from a concentrator to a stationary liquid oxygen system, prior to the end of the reasonable useful lifetime period, this does not result in the start of a new reasonable useful lifetime period or a new 36-month payment period.
  • In addition, if oxygen equipment isn't functioning properly and needs replaced prior to the end of the reasonable useful lifetime period, the action does not result in the start of a new reasonable useful lifetime period or a new 36-month payment period.
  • If the beneficiary switches to a new supplier and new equipment prior to the end of the reasonable useful lifetime period, the action does not result in the start of a new reasonable useful lifetime period or an new 36-month payment period.

Supplier Responsibilities Months 1-36

  • Oxygen rental covers equipment, contents, maintenance, supplies and accessories such as tubing or a mouthpiece, and other services necessary for furnishing oxygen and oxygen equipment.
  • Suppliers retain ownership of the oxygen equipment following the 36-month rental cap.
  • The supplier furnishing the oxygen equipment in the first month is required to continue furnishing oxygen equipment for the entire 36-month period with certain exceptions:
    • Beneficiary relocates outside service area
    • Beneficiary elects to obtain oxygen equipment from another supplier
  • Suppliers are prevented from switching oxygen equipment modalities during the 36-month period with a few exceptions:
    • Physician orders different equipment based on medical necessity
    • Beneficiary chooses new technology and signs an Advanced Beneficiary Notice of Noncoverage (ABN) acknowledging potential financial liability.

Suppliers Responsibilities Months 37-60

  • Suppliers are required to furnish equipment, supplies, and accessories for any period of medical need for the remainder of the reasonable useful lifetime of the equipment.
    • Includes use of equipment following temporary breaks of in-home oxygen services, e.g., hospital stay, of any duration
  • Supplier who furnished liquid or gaseous oxygen equipment during the 36th month period is responsible for furnishing oxygen contents used with the supplier-owned equipment for any period of medical necessity following the 36-month cap for the remainder of the useful lifetime of the equipment.
    • Use HCPCS codes E0441 through E0444 to bill oxygen contents.
  • Blue Cross of Idaho can pay for a general maintenance and servicing visit for concentrators (E1390, E1391, or E1392) or transfilling equipment (K0738), which can take place six months after the end of the six-month rental period.
    • Other than this general maintenance and servicing payment, payment is not allowed for any repair or maintenance and servicing of supplier-owned equipment, including any replacement part furnished as part of any repair or maintenance and servicing of oxygen equipment.
  • Supplier is responsible for furnishing all of the same items and services after the 36-month rental period as they furnished during the rental period.
    • With the exception of oxygen contents and general maintenance and servicing, the supplier must furnish these items and services without billing the beneficiary or Blue Cross of Idaho.
  • Payment is not allowed for supplier pickup or disposal of oxygen tanks or cylinders that are no longer needed.

Beyond RUL

The supplier has three options once the beneficiary reaches the five year reasonable useful lifetime (RUL).

  • Inform the beneficiary that the supplier will discontinue service and arrange for picking up the oxygen equipment. The beneficiary will need to find a new oxygen supplier and will start a new 36-month rental period.
  • Inform the beneficiary that they must receive replacement equipment and start a new 36-month rental period, if they want to continue receiving services from the current supplier. Coinsurance and deductible fees will apply.
    • The beneficiary should be informed that switching to a new supplier will likely require new equipment and a new 36-month rental period.
  • Continue servicing the beneficiary without replacing equipment and only bill:
    • Contents for portable, if the patient qualified; or
    • Maintenance and service for concentrators and transfilling equipment - E1309, E1391, E1392 and K0738.

If the beneficiary feels that the equipment is working fine and does not need to be replaced, the supplier is under no obligation to continue furnishing equipment beyond the five year reasonable useful lifetime.

Reference Table

Equipment Furnished in Month 36 Monthly Contents Payment after Stationary Cap
Oxygen Concentrator (E1390, E1391, or E1392) None
Portable Gaseous Transfilling Equipment (K0738) None
Portable Liquid Transfilling Equipment (E1399) None
Stationary Gaseous Oxygen System (E0424) Stationary Gaseous Contents (E0441)
Stationary Liquid Oxygen System (E0439) Stationary Liquid Contents (E0442
Portable Gaseous Oxygen System (E0431) Portable Gaseous Contents (E0443)
Portable Liquid Oxygen System (E0434) Portable Liquid Contents (E0444)

Ventilators

Blue Cross of Idaho will approve ventilator equipment as a rental item only and will not cap the purchase price. Specific member contract limitations and medical necessity determines coverage.


Policy History

Date Action Reason
March 2013 Revised Added CMS billing guidelines
October 2009 Revised Units revision/testing providers
March 2009 Revised Added ventilator information and HCPC standard language

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