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Date Printed: June 28, 2017: 11:50 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

09-E0400

Original Effective Date: 10/03/00

Reviewed: 05/26/16

Revised: 06/15/16

Subject: Oxygen

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates Decision Tree  
           

DESCRIPTION:

Oxygen therapy is the administration of oxygen via inhalation-utilizing devices that provide concentrations and flow rates for maintaining adequate tissue and cell oxygenation while avoiding oxygen toxicity.

This guideline is applicable to all home oxygen therapies that can be delivered utilizing stationary O2, portable O2, or transtracheal O2 methods.

Gaseous oxygen is considered to be more cost-effective than liquid oxygen.

POSITION STATEMENT:

 

Certificate of Medical Necessity

Submit a completed Certificate of Medical Necessity (CMN) along with your request to expedite the medical review process.

Click the link Oxygen - Certificate of Medical Necessity (MS Word) to open the form.

Complete all fields on the form thoroughly.

Print and submit a copy of the form with your request.

Note: Florida Blue regularly updates CMNs. Ensure you are using the most current copy of a CMN before submitting to Florida Blue. For a complete list of available CMNs, visit the Certificates of Medical Necessity page.

Home Oxygen Therapy:

Home oxygen therapy, whether by stationary, portable, or transtracheal methods, or concentrators, meets the definition of medical necessity when ALL of the following criteria are met:

• Oxygen is prescribed by the treating physician for a severe lung disease or hypoxia-related symptoms that may improve with oxygen therapy

• The physician prescribed ALL of the following:

­ The flow rate

­ An estimate of the frequency (i.e. 24 hours per day, during sleep, during activity)

­ Duration of use, AND

­ Duration of need.

• The oxygen flow can be regulated and is not preset locked at a preset rate

• The prescribed administration of oxygen is consistent with the member’s diagnosis of a severe lung disease, as defined by A and C or B and C below:

A. An arterial oxygen partial pressure (PO2) at or below 55 mm Hg (below 59mm with cor pulmonale, dependent edema suggestive of CHF, or erythrocythemia with HCT greater than 56%) as demonstrated by arterial blood gas measurements.

B. an O2 saturation at or below 88 percent (below 89 percent with cor pulmonale, dependent edema suggestive of CHF, or erythrocythemia with HCT greater than 56%) as demonstrated by arterial blood gas measurements.

C. symptoms associated with oxygen deprivation (i.e., impairment of cognitive processes, restlessness, or insomnia).

D. (Results can be obtained during rest, during activity, or during sleep.)

NOTES:

Initial claims for oxygen therapy: Initial claims for oxygen therapy should include results of an arterial blood gas study that has been ordered and evaluated by the attending physician (the preferred sources of lab evidence are physician OR hospital records reflecting the member’s medical condition).

An initial O2 saturation measurement obtained by pulse oximetry is acceptable when ordered and evaluated by the attending physician and performed under the physician’s supervision or when performed by a qualified provider /supplier of laboratory services.

The need for initial oxygen is supported by either a blood gas study or pulse oximetry reading closest to the discharge date from the hospital.

For members whose initial oxygen prescription did not come from a hospital stay, blood gas studies or pulse oximetry readings are to be done while the member is in a chronic stable state and not during a period of acute illness or exacerbation of the underlying condition.

Annual Renewal: An O2 saturation measurement obtained by pulse oximetry for annual renewal of oxygen services is acceptable when performed by a qualified provider/supplier of laboratory services or DME provider of oxygen and oxygen equipment.

Portable oxygen therapy:

Portable oxygen systems meet the definition of medical necessity when the member is mobile (i.e., ambulatory or wheelchair bound) within the home and when the qualifying blood gas study was performed while awake (at rest) or during exercise.

Portable oxygen systems are defined  as:   

1. Non-portable oxygen concentrators (E1390) and  portable oxygen canisters, or

2. Portable oxygen concentrators (E1392) that are capable of delivering 85% or greater oxygen concentration can operate either on AC/DC power. The unit must also be capable of functioning as a stationary concentrator, operating 24 hours per day, 7 days per week.

Portable oxygen systems (i.e. tanks or concentrators) used with stationary oxygen systems are indicated when the above guidelines for home oxygen use and portability are met.

If the only qualifying blood gas study was performed during sleep, portable oxygen is non-covered as not medically necessary.

Lightweight oxygen tanks may be eligible for coverage for members considered to be frail and unable to manage standard oxygen tanks.

If the coverage criteria for home oxygen therapy are met, portable oxygen systems are reimbursed separately, in addition to stationary systems.

Transtracheal oxygen therapy:

Transtracheal oxygen therapy provided in the home meets the definition of medical necessity when ALL of the following criteria are met:

• Transtracheal O2 is prescribed by a physician;

• Arterial oxygen saturation is equal to or less than 55mm Hg at 6 – 8 L/min delivery rate; AND

• Member is severely hypoxic and refractory to other methods of oxygen administration.

Oxygen administered for treating cluster headaches:

Oxygen and the related equipment meets the definition of medical necessity when used for the treatment of cluster headaches. A physician’s order for oxygen to be used for the treatment of cluster headaches should not be considered “PRN” oxygen. (Refer to Reimbursement Information section of this guideline.)

Oxygen used in conjunction with CPAP or bi-level PAP:

Oxygen used in conjunction with CPAP or bi-level PAP meets the definition of medical necessity when the member has an underlying chronic obstructive pulmonary disease (COPD) or pulmonary disease concomitantly with obstructive sleep apnea and demonstrates hypoxia despite PAP therapy. Supporting documentation should include results of an overnight pulse oximetry and physician’s progress notes. If the member has obstructive sleep apnea (OSA), the treatment should be toward relief of the obstruction with CPAP or bi-level PAP.

Note: O2 saturation testing must be completed during sleep while on PAP therapy to demonstrate that the member meets the criteria for oxygen therapy despite resolution of the airway obstruction.

Oxygen for nighttime use:

A physician’s order for oxygen to be used every night meets the definition of medical necessity when the above criteria for home oxygen therapy are met. Nighttime use should not be considered “PRN” oxygen.

Oxygen saturation test completed during sleep meets the above criteria for home oxygen therapy.

Oxygen therapy does not meet the definition of medical necessity for the following conditions:

• Angina pectoris in the absence of hypoxemia. This condition is generally not the result of a low O2 level in the blood and there are other preferred treatments.

Dyspnea 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 will improve the oxygenation of tissues with impaired circulation.

• Terminal illnesses that do not affect the respiratory system.

The following oxygen services and supplies are specifically not eligible for coverage:

• Preset regulators used with portable oxygen systems. Coverage criteria require that the oxygen flow can be regulated rather than preset.

• Regulators that permit a flow rate greater than 8 liters per minute. Such devices are not appropriate for home use.

• Extra tanks OR mini concentrators are considered convenience items and do not meet the definition of medical necessity.

• Prescriptions for oxygen “as needed” or “PRN”. “PRN oxygen” or “oxygen as needed” does not fulfill the above coverage criteria of physician prescribed flow rate, duration of use, and duration of need and does not provide a basis for determining if the amount of oxygen is reasonable and necessary for the member.

BILLING/CODING INFORMATION:

Oxygen equipment, contents, and related supplies are provided by DME suppliers and should be reported using the following HCPCS codes, in addition to the appropriate modifier, -NU (New equipment) or -RR (rental):

HCPCS Coding

NOTE: The inclusion of a code in this section does not necessarily imply coverage.

A4606

Oxygen probe for use with oximeter device, replacement

A4615

Cannula, nasal

A4616

Tubing (oxygen, per foot

A4617

Mouth piece

A4619

Face tent

A4620

Variable concentration mask

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, one month’s supply = 1 unit

E0442

Stationary oxygen contents, liquid, one month’s supply = 1 unit

E0443

Portable oxygen contents, gaseous, one month’s supply = 1 unit

E0444

Portable oxygen contents, liquid, one month’s supply = 1 unit

E0445

Oximeter device for measuring blood oxygen levels non-invasively

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 adaptor for portable concentrator, any type, replacement only, each

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 grater oxygen concentration at the prescribed flow rate, each

E1392

Portable oxygen concentrator, rental

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

K0740

Repair or non-routine service for oxygen equipment requiring the skill of a technician, labor component, per 15 minutes

S8120*

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

S8121*

Oxygen contents, liquid, 1 unit equals 1 pound*

Coding Notes:

* Oxygen contents billed for use with purchased oxygen equipment are reimbursed according to allowances for codes E0441 OR E0442 rather than S8120 OR S8121.

** In 2009, Medicare benefits for oxygen and related supplies changed to allow the equipment to be owned by the member after a certain period of rental time. E1354, E1356, E1357, and E1358 apply to oxygen equipment that is owned by the member and requires these replacement items.

Code E1391 (Oxygen concentrator, dual delivery port) is used in situations in which two individuals are both using the same concentrator. In this situation, this code should only be billed for one of the individuals.

Code E1392 describes an oxygen concentrator which is designed to be portable, is capable of delivering 85% or greater oxygen concentration, and is capable of operating on either AC or DC (e.g., auto accessory outlet) power. Code E1392 includes the device itself, an integrated battery or member-replaceable batteries that are capable of providing at least two hours of remote portability at a minimum of 2 liters per minute equivalency, a battery charger, an AC power adapter, a DC power adapter, and a carry bag and/or cart. The combined weight of the concentrator and the battery/batteries capable of two hours of portability must be 20 pounds or less. If a concentrator meets all of these criteria and is also capable of functioning as a stationary concentrator, operating 24 hours per day, 7 days per week, the stationary concentrator code (E1390) is billed in addition to code E1392.

Code K0738 describes a feature of an oxygen concentrator that allows the individual to fill portable gaseous oxygen cylinders from a stationary concentrator. This feature may be integrated into the stationary concentrator or may be a separate component. Code E0431 (portable gaseous oxygen system, rental) and K0738 should not be billed together (source: Medicare).

Code E0433 describes a feature of an oxygen concentrator that allows the individual to fill portable liquid oxygen cylinders from a stationary concentrator. This feature may be integrated into the stationary concentrator or be a separate component. When code E0433 is billed, code E0434 (portable liquid oxygen system, rental) must not be used.

REIMBURSEMENT INFORMATION:

1. Reimbursement for oxygen equipment is based on rental of the equipment, not purchase. However, in cases of indefinite or extended use, periodic review of medical records is recommended to determine that hypoxemia persists and the equipment continues to be medically necessary. Reassessment of the need for oxygen through pulse oximetry at rest and after exercise is required and must be performed yearly in order to re-qualify coverage of oxygen therapy. An O2 saturation measurement obtained by pulse oximetry for annual renewals is acceptable when performed by a qualified provider/supplier of laboratory services or DME provider of oxygen and oxygen equipment.

2. Reimbursement for accessories such as oxygen carts, racks, stands are included in the rental fee for the oxygen tank and are not eligible for coverage as a separate service.

3. Replacement transtracheal catheters (E1399) are limited to two (2) in a three (3) month period unless the medical record documents medical necessity.

4. Codes for the rental of oxygen equipment should be billed once per month.

5. Reimbursement for home oxygen and the associated equipment used for the treatment of cluster headaches is limited to one set-up for six (6) months.

6. Reimbursement for oxygen contents is included in the rental allowance for the oxygen system.

7. Reimbursement for portable oxygen contents is separately payable only when the coverage criteria for home oxygen have been met AND:

• The member owns a concentrator and rents or owns a portable system OR

• The member has no stationary system (i.e., concentrator, gaseous, or liquid) and rents or owns a portable system.

8. Reimbursement for setup or installation of respiratory support systems is included in the rental allowance for the oxygen equipment.

9. Reimbursement for oxygen-conserving devices (e.g., Oxylite) is considered included in the allowance for other covered oxygen equipment and supplies.

10. Reimbursement for maintenance, repairs, replacements, and adjustments of oxygen equipment is included in the rental allowance. A separate allowance is made for repair or equipment owned by the member. (K0740).

11. See Oxygen Reimbursment Table for additional information.

LOINC Codes:

The following information may be required documentation to support medical necessity: Oxygen must be prescribed by the treating physician - Documentation should include treating physician history and physical, and treatment notes including: established diagnosis; O2 saturation measurement, ABG study, and other pertinent information (i.e., hospital records, nursing home records, home health agency records, records from other healthcare professional and tests reports).

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician visit note or treatment notes

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Blood gas tests (i.e., ABG study)

18767-4

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Pulmonary studies (i.e., O2 saturation measurement)

27896-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician hospital discharge summary

11490-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Provider orders

46209-3

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician initial assessment

18736-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician consulting initial assessment

18763-3

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician consulting progress note

28569-2

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Clinical notes and chart section

28650-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Current, Discharge, or administered medications

34483-8

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Nurse initial assessment

29753-1

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Nursing note

46208-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Evaluation and Management services

X0013-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Home Health Certifications

X0016-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Letter of Medical Necessity

X0027-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Home Use of Oxygen in approved Clinical Trials (240.2.1) and Oxygen (240.2) located at cms.gov.

The following Durable Medical Equipment Regional Carrier (DMERC) Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Oxygen and Oxygen Equipment (L33797) located at cgsmedicare.com.

DEFINITIONS:

Chronic Stable State--chronic stable state is when a patient is not experiencing a period of acute illness or an exacerbation of their underlying disease.

Cluster headache: Cluster headaches are not synonymous to tension or migraine headaches, but consist of recurrent episodes of unilateral, orbital, supraorbital, or temporal head pain usually accompanied by conjunctival injection, lacrimation, rhinorrhea, nasal congestion, ptosis, miosis, eyelid edema, and facial sweating. Attacks can last between 15 minutes and 3 hours and may occur as infrequently as every other day or as frequently as eight attacks per day. The name for this syndrome is derived from the characteristic clusters or periods of frequent headaches that last from weeks to months separated by periods of months or years of being headache-free. Headaches typically occur at the same time each day and assume a temporal cyclicity. Nitrates and alcohol trigger an onset of cluster headaches. Cluster headaches occur more typically in males (male to female ratio 6:1).

Concentrator: manufactures oxygen using a molecular sieve and electricity; does not require filling or refilling with gaseous or liquid oxygen.

Dyspnea: breathlessness.

Hypoxemia: insufficient oxygenation of the blood.

Oxygen Conserving devices: Oxygen conserving devices can substantially increase the range of a liquid portable or small high- pressure gas system. Some devices are mechanical/pneumatic and others are battery powered. The initiation of inspiration causes a pulse flow of oxygen to be delivered. Not all conserving devices deliver the same amount of oxygen. Checking for adequacy of oxygenation by the use of pulse oximetry, particularly during exercise, should be done when conserving devices are used. The classification of conservers is often misleading. Some conservers are referred to as demand devices because they are triggered by patient demand even though they only deliver a fixed pulse. In reality, there are two general classifications of oxygen conservers. Those that deliver a fixed volume per breath are classified as pulsing devices. Those that deliver a variable volume (commensurate with the length of inspiration) are demand devices. Other demand devices deliver for a fixed time that is approximately the length of inhalation.

Portable oxygen system: filled/refilled from a stationary oxygen system.

PRN: as needed.

Pulse oximeter (pulse ox): a device placed on the skin (i.e., finger, ear, forehead) to measure how much oxygen is being carried by the red blood cells.

Stationary oxygen system: requires filling/refilling from a source; is not portable.

Transtracheal oxygen therapy: method of delivering oxygen directly into the windpipe via catheter connection.

RELATED GUIDELINES:

Hyperbaric Oxygen Therapy (HBO2), 01-99180-01
Positive Airway Pressure Devices, 09-E0000-21

Home Pulse Oximetry, 09-E0000-49

OTHER:

None applicable.

REFERENCES:

  1. Blue Cross Blue Shield Association Medical Policy 01.01.12 Oxygen, archived 2010.
  2. Cecil Textbook of Medicine, 21st edition; Goldman (2000).
  3. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination for Home Oxygen Use to Treat Cluster Headache 240.2.2; 02/15/11.
  4. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination for Home Use of Oxygen in Approved Clinical Trials, Publication 100-3, and Section 240.2.1 (04/06).
  5. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination for Home Use of Oxygen 240.2 (10/27/93).
  6. Centers for Medicare & Medicaid Services (CMS). Region C DMERC Article for Oxygen and Oxygen Equipment Policy Article (payment rules and coding guidelines), (01/10).
  7. Centers for Medicare & Medicaid Services (CMS). Region C DMERC Local Carrier Determination (LCD) L33797 for Oxygen and Oxygen Equipment, 10/15.
  8. Conn’s Current Therapy 2000, 52nd edition; Rakel (2000).
  9. HCPCS Level II Coding (current edition).
  10. National Lung Health Education Program: Thomas L Petty, MD; “Guide to Prescribing Home Oxygen: Home Oxygen Options” (09.03). Accessed 03/11/09.
  11. Textbook of Clinical Neurology, 1st edition; Goetz (2000).

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 05/26/16.

GUIDELINE UPDATE INFORMATION:

08/15/99

Medical Coverage Guideline Reformatted.

02/22/01

Added Cluster Headaches as covered.

09/01/01

Added code S8105.

10/01/02

Added modifier NU (New equipment).

01/01/03

Annual HCPCS coding update.

03/15/03

Reviewed; Oxygen Matrix updated to remove deleted codes.

10/01/03

4th Quarter HCPCS update (added S8120, S8121).

08/15/04

Scheduled review with revisions to guideline consisting of adding E1391 to reimbursement table, added statement regarding use of oxygen with CPAP/BiPAP; added statement regarding oxygen used every night; added reimbursement statement for oxygen contents; removed home pulse oximetry information (separate MCG developed); formatting changes.

01/01/05

Annual HCPCS coding update: revised descriptor for E0450; added E0461. Added clarification of coverage for cluster headaches.

04/01/05

2nd Quarter HCPCS coding update; added K0671 to coding section and Oxygen Reimbursement Table; removed S8121 from Oxygen Reimbursement Table.

01/01/06

Annual HCPCS coding update: replace K0671 with E1392.

04/15/06

Scheduled review (consensus review); no changes in coverage statement.

10/01/06

4th HCPCS quarter coding update: added K0738.

08/15/07

Reviewed; add information regarding mini-concentrators; change coverage statement for lightweight oxygen tanks; reformatted guideline; revised reimbursement requirements; added Medicare Advantage Program Exception regarding home oxygen use and clinical trials; updated references.

01/01/09

Annual HCPCS coding update: added E1354, E1356, E1357, and E1358.

05/15/09

Scheduled review: no change in position statements; update Program Exceptions for Medicare Advantage products; references updated; formatting changes.

07/01/09

3rd quarter HCPCS coding update: added K0740; added reimbursement statement for maintenance, repairs, replacements, and adjustments of oxygen equipment.

01/01/10

Annual HCPCS coding update: added E0433 to coding section and reimbursement matrix; revised descriptors for A0441, A0442, A0443, and A0444.

07/15/10

Revisions to Coding and Reimbursement sections and Oxygen Reimbursement Matrix; references updated.

11/15/10

Revisions consisting of formatting changes.

03/15/11

Revisions consisting of formatting changes.

07/01/11

3rd Quarter HCPCS coding update: Added codes K0741 and K0742.

09/15/11

Revision; formatting changes. Revision; Reimbursement Table updated.

01/01/13

Annual HCPCS coding update: deleted K0741 and K0742.

04/01/13

Revision to add Program Exception for Medicare Advantage products.

01/01/14

Annual HCPCS coding updated: added E1352. Updated Program Exceptions section.

05/15/15

Revision; position statement section updated; formatting changes.

01/01/16

Annual HCPCS/CPT update; codes E0450 and E0461 deleted.

06/15/16

Revision; position statement section, reimbursement section, program exception and references updated.

Date Printed: June 28, 2017: 11:50 PM