Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Home Oxygen Therapy

Policy #:05.00.58l

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

MEDICALLY NECESSARY

Home oxygen therapy is considered medically necessary and, therefore, covered when all of the following criteria are met:
  • The treating professional provider has determined that the individual has severe lung disease or hypoxia-related symptoms that may improve with oxygen therapy.
  • The individual's blood gas study or pulse oximetry study meets the criteria in Group I or II, stated below, with the following exception:
    • A pulse oximetry study and/or an arterial blood gas test may not be required for pediatric individuals with conditions such as pulmonary hypertension, broncho-pulmonary dysplasia, or respiratory distress of newborn when it would be clinically inappropriate to reduce oxygen treatment to obtain a pulse oximetry study and/or an arterial blood gas test on room air.
  • The qualifying blood gas study or pulse oximetry study was performed by a qualified provider.
  • The qualifying blood gas study or pulse oximetry study was obtained under one of the following conditions:
    • If 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.
    • If not performed during an inpatient hospital stay, the reported test must be performed while the individual is in a chronic stable state (ie, not during a period of acute illness, an exacerbation of their underlying disease).
  • Alternative treatment measures have been tried or deemed clinically ineffective (e.g., nebulizer treatments, steroid therapy).

GROUP I CRITERIA
(Initial approval for up to 12 months)

Criteria from one of the following categories (e.g., at rest, during exercise, or during sleep) must be met.

Individual Tested on Room Air
at Rest
Individual Tested on Room Air During Exercise
Individual Tested During Sleep
While awake:
  • Arterial oxygen saturation or pulse oximetry study at or below 88%; or
  • Arterial Partial Pressure of Oxygen (PO2) at or below 55 mm Hg.
During exercise:
  • An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent, for an individual who demonstrates an arterial PO2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89 percent during the day while at rest; and
  • Documented improvement of hypoxemia with oxygen.
If arterial PO2 at or above 56 mm Hg or an arterial oxygen saturation or pulse oximetry study at or above 89% while awake, additional testing must show:
  • Arterial PO2 at or below 55 mm Hg, or an arterial oxygen saturation or pulse oximetry study at or below 88%, for at least 5* minutes taken during sleep; or
  • Decrease in arterial PO2 of more than 10 mm Hg, or a decrease in arterial oxygen saturation or pulse oximetry study more than 5%, for at least 5* minutes, taken during sleep associated with symptoms or signs reasonably attributable to hypoxemia.
    • Nocturnal restlessness with impaired cognitive processes
    • Insomnia with impaired cognitive processes
    • Cor pulmonale
    • “P” pulmonale on EKG ) (P wave greater than 3 mm in standard leads II, III, or aVF);or
    • Documented pulmonary hypertension
    • Erythrocytosis
*For all the sleep oximetry criteria described above, the 5 minutes do not have to be continuous.

Group 1 Certification and Recertification Requirements

The following requirements must be met.

Certification requirements to establish initial medical need:

Initial Certification Requirements
Testing Requirements
Professional Provider Visit Requirements
With the first claim for home
oxygen
  • Initial coverage for individuals meeting Group I criteria is limited to 12 months or the professional provider specified length of need, whichever is shorter.
The blood gas study or pulse oximetry study must be the most recent study obtained within 30 days prior to the Initial Date.The individual must be seen and evaluated by the treating professional provider within 30 days prior to the date of Initial Certification.

Recertification requirements to confirm medical need still exists:

Recertification Requirements
Testing Requirements
Professional Provider Visit Requirements
12 months after Initial
Certification; that is, with the 13th month’s claim.
The blood gas study, which refers to either a or pulse oximetry study or an arterial blood gas test, must be the most recent study obtained prior to the 13th month of therapy.For individuals initially meeting
Group I criteria, the treating professional provider must see and re-evaluate the individual within 90 days prior to the date of any Recertification.


GROUP II CRITERIA
(Initial approval for up to 3 months)

Criteria from one of the following categories ( i.e., at rest, during exercise, or during sleep) must be met.

Individual Tested on Room Air at Rest
Individual Tested During Exercise
Individual Tested During Sleep
While awake:
  • Arterial oxygen saturation or pulse oximetry study of 89%; or
  • Arterial PO2 of 56-59 mm Hg; and any of the following:
    a. Dependent edema suggesting congestive heart failure;
    b. Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or “P” pulmonale on electrocardiography (EKG) (P wave greater than 3 mm in standard leads II, III, or aVF); or
    c. Erythrocythemia with a hematocrit above 56%.
As described under Group I criteria; and any of the following:
  1. Dependent edema suggesting congestive heart failure;
  2. Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or “P” pulmonale on electrocardiography (EKG) (P wave greater than 3 mm in standard leads II, III, or aVF); or
  3. Erythrocythemia with a hematocrit above 56%.
The individual demonstrates during sleep for at least 5* minutes:
  • Arterial oxygen saturation or pulse oximetry study of 89%; or
  • Arterial PO2 of 56-59 mm Hg; and any of the following:
    a. Dependent edema suggesting congestive heart failure;
    b. Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or “P” pulmonale on electrocardiography (EKG) (P wave greater than 3 mm in standard leads II, III, or aVF);or
    c. Erythrocythemia with a hematocrit above 56%.
*For all the sleep oximetry criteria described above, the 5 minutes do not have to be continuous.


GROUP II CERTIFICATION AND RECERTIFICATION REQUIREMENTS
The following requirements must be met.

Certification requirements to establish initial medical need:

Initial Certification Requirements
Testing Requirements
Professional Provider Visit Requirements
With the first claim for home
Oxygen
  • Initial coverage for individuals meeting Group II criteria is limited to 3 months or the professional provider specified length of need, whichever is shorter.
The blood gas study or pulse oximetry study must be the most recent study obtained within 30 days prior to the Initial Date.The individual must be seen and evaluated by the treating professional provider within 30 days prior to the date of Initial Certification.

Recertification requirements to confirm medical need still exists:

Recertification Requirements
Testing Requirements
Professional Provider Visit Requirements
3 months after Initial
Certification; that is, the fourth month’s claim.
The most recent blood gas study or pulse oximetry study performed between the 61st and 90th day following initial certification must be reported on the recertification.The individual must be seen and re-evaluated by the treating professional provider within 90 days prior to the date of the recertification.

Recertification requests for Replacement Equipment
  • Use the most recent qualifying arterial oxygen saturation or pulse oximetry study. This test does not have to be within 30 days prior to the initial date. It can be the test reported on the most recent certification.
  • There is no requirement for a professional provider visit related to the certification for replacement of equipment.

CLUSTER HEADACHES
For individuals enrolled in the Company's Commercial products, home oxygen is considered medically necessary and, therefore, covered for the treatment of individuals diagnosed with cluster headaches.

Certification Requirements:
  • Initial coverage for individuals with cluster headaches is limited to 12 months or the professional provider-specified length of need, whichever is shorter.

Recertification Requirements (not required in situations of replacement equipment):
  • The individual must be seen and re-evaluated by the treating professional provider for continued use beyond 12 months.

When both arterial blood gas (ABG) and pulse oximetry study have been performed on the same day under the same conditions (ie, at rest/awake, during exercise, during sleep) the ABG result will be used to determine if the coverage criteria were met. If an ABG test at rest/awake is nonqualifying, but an exercise or sleep oximetry study on the same day is qualifying, the oximetry study will determine the coverage.

PORTABLE OXYGEN
Portable oxygen systems are considered medically necessary and, therefore, covered when the individual is mobile within the home and the qualifying blood gas study or pulse oximetry study was performed while at rest (awake) or during exercise. If the only qualifying blood gas study or pulse oximetry study was performed during sleep, portable oxygen is considered not medically necessary and, therefore, not covered.

NOT MEDICALLY NECESSARY

GROUP III CRITERIA
Home oxygen therapy is considered not medically necessary and, therefore, not covered when either of the following Group III criteria are present:
  • The individual demonstrates arterial PO2 levels at or above 60 mmHg.
  • The individual demonstrates arterial blood oxygen saturations or pulse oximetry study at or above 90 percent.

Home oxygen therapy is considered not medically necessary and, therefore, not covered in the treatment of the following conditions:
  • 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.
  • Dyspnea without cor pulmonale or evidence of hypoxemia.
  • Terminal illnesses that do not affect the respiratory system.
  • Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities but in the absence of systemic hypoxemia. There is no evidence that increased PO2 will improve the oxygenation of tissues with impaired circulation.

If all of the coverage conditions specified above for Group I or Group II criteria are not met, home oxygen therapy is considered not medically necessary and, therefore, not covered.

EMERGENCY OR STAND-BY OXYGEN
Emergency or stand-by oxygen for individuals who are not currently meeting the requirements for oxygen is considered not medically necessary, and, therefore, not covered.

PRESCRIPTION RENEWAL

A revised prescription for home oxygen therapy is required in any of the following situations:

Revised Certification Requirements
Testing Requirements
Professional Provider Visit Requirements
1. When the prescribed maximum flow rate changes from one of the following categories to another:
  1. Less than 1 Liter per Minute (LPM),
  2. 1-4 LPM, or
  3. Greater than 4 LPM.

2. When the length of need expires, if the professional provider specified less than lifetime length of need on most recent letter of necessity.
The blood gas study or pulse oximetry study must be the
most recent study obtained within
30 days prior to the revised date.
  • If the change is from category (a) or (b) to category (c), a repeat blood gas study or pulse oximetry study with the individual on 4 LPM must be performed
There is no requirement for a professional provider visit.
3. When a portable oxygen
system is added subsequent to Initial Certification of a stationary system.
There is no requirement for a
repeat blood gas study or pulse oximetry study unless
the initial qualifying study was
performed during sleep, in
which case a repeat blood gas
study or pulse oximetry study must be performed while
the individual is at rest (awake) or during exercise within 30 days prior to the Revised Date.
There is no requirement for a professional provider visit.
4. When a stationary system is
added subsequent to Initial
Certification of a portable system.
No blood gas study or pulse oximetry study is required.There is no requirement for a professional provider visit.
5. When there is a new treating
professional provider, but the oxygen order is the same; or

6. If there is a new DME provider, and the new DME provider does not have the prior prescription.
No blood gas study or pulse oximetry study is required.There is no requirement for a professional provider visit.

OXYGEN ACCESSORIES AND SUPPLIES

The Non-invasive Open ventilation system (NIOV) (E1352), by Breath Technologies, Inc. provides positive pressure inspiratory support for individuals using oxygen. This product consists of (control unit, flow regulator, connecting hose and nasal interface (pillows) (A9900). Per the manufacturer, the NIOV is an item that's effective only when used in conjunction with oxygen. An item that is effective only when used in conjunction with oxygen; is therefore, classified as an accessory to oxygen equipment.

All home oxygen therapy equipment from contracted providers is rented rather than purchased. Oxygen supplies and accessories (eg, nasal cannula, tubing, face mask, oxygen conserving devices) are included in the rental reimbursement and are therefore, not eligible for separate reimbursement.

TESTING SPECIFICATIONS

Overnight oximetry refers to stand-alone pulse oximetry continuously recorded overnight. It does not include oximetry results done as part of other overnight testing for sleep apnea such as polysomnography (PSG) or home sleep testing.

For home overnight oximetry studies, the oximetry provided to the individual must be tamper proof, have the capability to download data, allow documentation of the duration of oxygen desaturation below a specified value and be under the direction of Diagnostic Testing Facility.

For individuals with obstructive sleep apnea (OSA), this means that the OSA must be sufficiently treated such that the underlying severe lung disease is unmasked. This must be demonstrated before oxygen saturation results obtained during polysomnography are considered qualifying for oxygen therapy. A qualifying oxygen saturation study may only occur during a titration polysomnographic study (either split night or stand-alone) if 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 ten (10) events per hour, the titration demonstrates further reduction in the AHI/RDI; and
  3. Nocturnal oximetry conducted for the purpose for oxygen reimbursement qualification may only be performed after optimal positive airway pressure (PAP) settings have been determined and the individual is using the PAP device at those settings; and
  4. The nocturnal oximetry conducted during the PSG demonstrates an oxygen saturation ≤ 88% for 5 minutes total (which need not be continuous)

When oxygen is covered based on an oxygen study obtained during exercise, there must be documentation of three oxygen studies in the individual's medical record (ie, testing at rest without oxygen, testing during exercise without oxygen, testing during exercise with oxygen applied [to demonstrate the improvement of the hypoxemia]). All three tests must be performed within the same testing session. Only the qualifying test value (ie, testing during exercise without oxygen) is reported on the Certificate of Medical Necessity. The other results do not have to be routinely submitted but must be available on request.

The qualifying blood gas study or pulse oximetry test may be performed while the individual is on oxygen as long as the reported blood gas or pulse oximetry study values meet the Group I or Group II criteria.

FACE-TO-FACE REQUIREMENTS

As a condition for payment, a professional provider must have a face-to-face examination with the individual for whom the item is ordered that meets all of the following requirements:
  • The treating professional provider must have an in-person examination with the individual within the six (6) months prior to the date of the written order prior to delivery.
  • This examination must document that the individual was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered.

A new face-to-face examination is required each time a new prescription for one of the specified items is ordered. A new prescription is required:
  • For all claims for purchases or initial rentals
  • When there is a change in the prescription for the accessory, supply, drug, etc.
  • If periodic prescription renewal required per medical policy
  • When an item is replaced
  • When there is a change in the supplier
  • When required by state law

In this policy the specified items are:

E0424 STATIONARY COMPRESSED GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES CONTAINER, CONTENTS, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND TUBING
E0431 PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE CONTAINER, REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASK, AND TUBING
E0433 PORTABLE LIQUID OXYGEN SYSTEM, RENTAL; HOME LIQUEFIER USED TO FILL PORTABLE LIQUID OXYGEN CONTAINERS, INCLUDES PORTABLE CONTAINERS, REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASK AND TUBING, WITH OR WITHOUT SUPPLY RESERVOIR AND CONTENTS GAUGE
E0434 PORTABLE LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE CONTAINER, SUPPLY RESERVOIR, HUMIDIFIER, FLOWMETER, REFILL ADAPTOR, CONTENTS GAUGE, CANNULA OR MASK, AND TUBING
E0439 STATIONARY LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES CONTAINER, CONTENTS, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, & TUBING
E0441 STATIONARY OXYGEN CONTENTS, GASEOUS, 1 MONTH’S SUPPLY = 1 UNIT
E0442 STATIONARY OXYGEN CONTENTS, LIQUID, 1 MONTH’S SUPPLY = 1 UNIT
E0443 PORTABLE OXYGEN CONTENTS, GASEOUS, 1 MONTH’S SUPPLY = 1 UNIT
E0444 PORTABLE OXYGEN CONTENTS, LIQUID, 1 MONTH’S SUPPLY = 1 UNIT
E0447PORTABLE OXYGEN CONTENTS, LIQUID, 1 MONTH'S SUPPLY = 1 UNIT, PRESCRIBED AMOUNT AT REST OR NIGHTTIME EXCEEDS 4 LITERS PER MINUTE (LPM)


REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

Documentation of a face to face encounter, between the treating professional provider and the individual meeting the above requirements, including an assessment of the individual’s clinical condition supporting the need for the prescribed DME item(s) must be provided to and kept on file by the DME supplier.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, home oxygen therapy is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as not medically necessary are not eligible for coverage or reimbursement by the Company.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

There are numerous devices approved by the FDA for home oxygen therapy.

Description

Home oxygen therapy is most commonly used to treat chronic, stable medical conditions that cause significant hypoxemia, such as severe lung disease (e.g., chronic obstructive pulmonary disease [COPD], interstitial fibrosis, cystic fibrosis, pulmonary neoplasm), pulmonary hypertension, and congestive heart failure related to cor pulmonale. Appropriate evidence of significant hypoxemia includes arterial blood gas studies, pulse oximetry, and certain clinical signs such as elevated pulmonary artery pressure, dependent edema, and polycythemia vera.

Home oxygen has been used for cluster headache (CH), which is a rare condition characterized by brief attacks of sudden, severe unilateral and periorbital pain. CH sufferers can have multiple attacks in a day, with each attack lasting anywhere from 15 minutes to 3 hours. Attacks are typically clustered over a period of 4 to 6 weeks. The intensity of pain is usually incapacitating throughout the duration of the attack. Studies have shown that the use of normobaric oxygen (oxygen at room pressure) delivered via a portable tank and face mask at a flow rate of 6 to 10 L/min for 5 to 15 min during an attack is effective in stopping the attack (abortive therapy).

Home oxygen therapy may be delivered via nasal cannula, face mask, or transtracheal catheter. Supply sources include a stationary or portable compressed gas tank, stationary or portable liquid oxygen tank, or stationary oxygen concentrator. Any item that is effective only when used in conjunction with oxygen is, therefore, classified as an accessory to oxygen equipment.
References


Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD).240.2: Home use of oxygen. [CMS Web site]. 10/27/93. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=169&ncdver=1&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=Pennsylvania&KeyWord=oxygen&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAA&. Accessed March 12, 2018.

Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD). 240.2.2: National Coverage Determination (NCD) for Home OXYGEN Use to Treat Cluster Headache. [CMS Web site]. 01/04/2011. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=343&ncdver=1&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=Pennsylvania&KeyWord=oxygen&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAA&. Accessed March 12, 2018.

Noridian Healthcare Solutions, LLC. Policy Article A52514. Oxygen and oxygen equipment. Revision effective 01/01/2017. Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/Oxygen+and+Oxygen+Equipment+LCD+and+PA/7f6a39d8-0342-4478-b1f5-1dd4839ef366. Accessed March 12, 2018.

Noridian Healthcare Solutions, LLC. Local Coverage Determination (LCD). L33797: Oxygen and oxygen equipment. Revision effective 01/01/2017. Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/Oxygen+and+Oxygen+Equipment+LCD+and+PA/7f6a39d8-0342-4478-b1f5-1dd4839ef366. Accessed March 12, 2018.

Noridian Healthcare Solutions, LLC. Breathe NIOV™ - Coding Reminder. October 2016. Available at:
https://med.noridianmedicare.com/web/jadme/search-result/-/view/2230703/breathe-niov-coding-reminder. Accessed March 12, 2018.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

Report the most appropriate diagnosis code in support of medically necessary criteria as listed in the policy.


HCPCS Level II Code Number(s)



MEDICALLY NECESSARY

E0424 Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing

E0425 Stationary compressed gas system, purchase; includes regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing

E0430 Portable gaseous oxygen system, purchase; includes regulator, flowmeter, humidifier, cannula or mask, and tubing

E0431 Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing

E0433 Portable liquid oxygen system, rental; home liquefier used to fill portable liquid oxygen containers, includes portable containers, regulator, flowmeter, humidifier, cannula or mask and tubing, with or without supply reservoir and contents gauge

E0434 Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing

E0435 Portable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing, and refill adapter

E0439 Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing

E0440 Stationary liquid oxygen system, purchase; includes use of reservoir, contents indicator, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing

E0441 Stationary oxygen contents, gaseous, 1 month's supply = 1 unit

E0442 Stationary oxygen contents, liquid, 1 month's supply = 1 unit

E0443 Portable oxygen contents, gaseous, 1 month's supply = 1 unit

E0444 Portable oxygen contents, liquid, 1 month's supply = 1 unit

E0447 Portable oxygen contents, liquid, 1 month's supply = 1 unit, prescribed amount at rest or nighttime exceeds 4 liters per minute (lpm)

E1390 Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate

E1391 Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate, each

E1392 Portable oxygen concentrator, rental

E1405 Oxygen and water vapor enriching system with heated delivery

E1406 Oxygen and water vapor enriching system without heated delivery

K0738 Portable gaseous oxygen system, rental; home compressor used to fill portable oxygen cylinders; includes portable containers, regulator, flowmeter, humidifier, cannula or mask, and tubing

S8120 Oxygen contents, gaseous, 1 unit equals 1 cubic foot

S8121 Oxygen contents, liquid, 1 unit equals 1 pound

NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

A4608 Transtracheal oxygen catheter, each

A4615 Cannula, nasal

A4616 Tubing (oxygen), per foot

A4617 Mouthpiece

A4619 Face tent

A4620 Variable concentration mask

A7525 Tracheostomy mask, each

E0455 Oxygen tent, excluding croup or pediatric tents

E0555 Humidifier, durable, glass or autoclavable plastic bottle type, for use with regulator or flowmeter

E0580 Nebulizer, durable, glass or autoclavable plastic, bottle type, for use with regulator or flowmeter

E1352 Oxygen accessory, flow regulator capable of positive inspiratory pressure

E1353 Regulator

E1354 Oxygen accessory, wheeled cart for portable cylinder or portable concentrator, any type, replacement only, each

E1355 Stand/rack

E1356 Oxygen accessory, battery pack/cartridge for portable concentrator, any type, replacement only, each

E1357 Oxygen accessory, battery charger for portable concentrator, any type, replacement only, each

E1358 Oxygen accessory, DC power adapter for portable concentrator, any type, replacement only, each

THE FOLLOWING CODE IS USED TO REPRESENT REPLACEMENT PILLOWS AND HOSES FOR THE NONINVASIVE OPEN VENTILATION SYSTEM (NIOV) (E1352)

A9900 Miscellaneous DME supply, accessory, and/or service component of another HCPCS code



Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

05.00.58l
01/01/2019This policy has been identified for the HCPCS code update effective 01/01/2019.

The following HCPCS code has been added to this policy:

E0447 Portable oxygen contents, liquid, 1 month's supply = 1 unit, prescribed amount at rest or nighttime exceeds 4 liters per minute (lpm)

05.00.58k
05/21/2018This version of the policy will become effective 05/21/2018.

This policy was updated for clarification on the use of home oxygen therapy and requirements for pediatric individuals when it would be clinically inappropriate to obtain a pulse oximetry study and/or an arterial blood gas on room air.

05.00.58j
04/01/2018This version of the policy will become effective 04/01/2018.
  • The following Modifiers have been revised in this policy:
    QE Modifier
    FROM: Prescribed amount of oxygen is less than 1 liter per minute (LPM)
    TO: Prescribed amount of stationary oxygen while at rest is less than 1 liter per minute (lpm)

    QF Modifier
    FROM: Prescribed amount of oxygen exceeds 4 liters per minute (LPM) and portable oxygen is prescribed
    TO:Prescribed amount of stationary oxygen while at rest exceeds 4 liters per minute (lpm) and portable oxygen is prescribed

    QG Modifier
    FROM: Prescribed amount of oxygen is greater than 4 liters per minute (LPM)
    TO: Prescribed amount of stationary oxygen while at rest is greater than 4 liters per minute (lpm)
  • The following Modifiers been added to this policy:
    QA Prescribed amounts of stationary oxygen for daytime use while at rest and nighttime use differ and the average of the two amounts is less than 1 liter per minute (lpm)

    QB Prescribed amounts of stationary oxygen for daytime use while at rest and nighttime use differ and the average of the two amounts exceeds 4 liters per minute (lpm) and portable oxygen is prescribed

    QR Prescribed amounts of stationary oxygen for daytime use while at rest and nighttime use differ and the average of the two amounts is greater than 4 liters per minute (lpm)


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 01/01/2019
Version Issued Date: 01/02/2019
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.