Chart Notes and Saturation Study
Chart Notes (initial notes) should include the following:
- Prescription details (liter flow, method of administration, etc.)
- Patient status at the time of need for oxygen therapy (inpatients vs. outpatients.) If inpatient, admission date and discharge date
- Date the provider is evaluating the test results. If portability, document that the patient is mobile in the home.
- Reason patient is expected to improve with oxygen therapy.
If Group I or II:
- Test date (for inpatients, must be performed within two (2) days of discharge. For outpatients, because of the undefined restriction in the LCD, no more than three (3) months, ask for a free text explanation after 30 days)
- Test type (Pulse ox or ABG)
- Test condition (rest, exercise, sleep – for no portability, titration- for outpatient/bleed into pap/OSA)
- Test results – (Does not qualify if no <89%. > 59 mmHG)
If Group II includes all of the following:
- An Arterial PO2 of 56-59 mm Hg or an arterial blood oxygen saturation of 89%; and,
- Any of the following:
- Dependent edema suggesting congestive heart failure; or,
- Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or “P” pulmonated on EKG (P wave greater than 3 mm in standard leads II, III or AVF); or
- Erythrocythemia with a hematocrit greater than 56%
If Group III:
- What is the patient’s condition that will likely improve with oxygen therapy?
- Any concerns for variations in oxygen measurements that may result from such factors as the patients age, the patients skin pigmentation, the altitude level, or a decrease in oxygen carrying capacity.
