1. Completion of a Physical Exam.
The first step for any medical treatment is consulting with and being evaluated by your treating practitioner. Your treating practitioner will determine if you meet the criteria for oxygen therapy at home. The treating practitioner will check to see if you have a respiratory condition impacting your breathing and preventing your body from maintaining healthy oxygen levels. Common conditions meeting home oxygen requirements include congestive heart failure and chronic obstructive pulmonary disease (COPD).
2. Testing Criteria.
Initial claims for oxygen therapy for hypoxemic patients must be based on the results of a clinical test that has been ordered and evaluated by the treating practitioner. It is common to test the blood oxygen level to confirm the patient’s eligibility for home oxygen therapy. The results of the study, rated by the practitioner, will reveal whether you have diminished oxygen levels. To qualify for oxygen therapy, you must meet one of the following criteria:
To qualify for Group I – qualifications for oxygen therapy is limited to 12 months or the treating practitioner-specified length of need, whichever is shorter – the following criteria must be met:
- An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent taken at rest (awake), or
- An arterial PO2 at or below 55 mm Hg, or an arterial oxygen saturation at or below 88 percent, for at least 5 minutes taken during sleep for a patient who demonstrates an arterial PO2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89 percent while awake, or
- A decrease in arterial PO2 more than 10 mm Hg, or a decrease in arterial oxygen saturation more than 5 percent from baseline saturation, for at least 5 minutes taken during sleep associated with symptoms (e.g., impairment of cognitive processes and [nocturnal restlessness or insomnia]) or signs (e.g., cor pulmonale, "P" pulmonale on EKG, documented pulmonary hypertension and erythrocytosis) reasonably attributable to hypoxemia, or
- An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent, taken during exercise for a patient 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. In this case, oxygen is provided for during exercise if it is documented that the use of oxygen improves the hypoxemia that was demonstrated during exercise when the patient was breathing room air.
To qualify for Group II – qualifications for oxygen therapy is limited to 3 months or the treating practitioner-specified length of need, whichever is shorter – the following criteria must be met:
A. An arterial PO2 of 56-59 mm Hg or an arterial blood oxygen saturation of 89 percent at rest (awake), during sleep for at least 5 minutes, or during exercise (as described under Group I criteria), and
B. Any of the following:
1. Dependent edema suggesting congestive heart failure, or
2. Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or "P" pulmonale on EKG (P wave greater than 3 mm in standard leads II, III, or AVF), or
3. Erythrocythemia with a hematocrit greater than 56 percent.
The required qualifying blood gas study must be performed at the time of need, which is during the time when it is presumed that providing oxygen therapy in the home will cause the patient’s condition to improve.
3. Obtaining Medical Documentation.
Claims for oxygen must be supported by medical documentation in the patient's record. After completing the physical evaluation and qualifying clinical test, we will need to work with your prescribing practitioner to obtain documentation, confirming you have a respiratory condition qualifying you for oxygen therapy. The documentation should include a diagnosis, details about how long you have had the condition, and a projection of whether the respiratory condition is improving or worsening. Also, to ensure you can get an oxygen tank at home, your records must confirm that you are able to maintain and use the equipment on your own safely.
4. Secure a Prescription.
Once you have completed the necessary tests and we have received a copy of your medical records detailing your condition, a formal written prescription from your practitioner is required. Typically, the prescription comes within 30 days from the date of your physical evaluation. The prescription should include a summary of your condition, detailing the need for home oxygen, the length of time and frequency for which oxygen therapy will be medically necessary, and the flow rate. For purposes of Medicare or payors that follow Medicare guidelines, a prescription for “Oxygen PRN” or “Oxygen as needed” does not meet this requirement, as neither provides the basis for determining the amount of oxygen reasonable or necessary for the patient.
5. Acquire Additional Forms as Required by the Payer.
The final step is to have your practitioner complete any forms your payer specifically requires. Oxygen therapy can be costly when factoring in equipment, clinical assistance, and any oxygen refills you may need. Your insurance company will require proof of your diagnosis to cover the cost. Your practitioner should detail the diagnosis of your condition in addition to the following information:
- How long you will need oxygen therapy
- Your blood oxygen level or pulse oximetry reading
- A summary of your arterial blood gas study
- Portability information
- Liter flow amount
- Practitioner's signature
Why Home Oxygen Therapy?
If you have a severe respiratory condition, you may not realize its impact on your daily life. Giving your body the oxygen it requires can help you reclaim the health-related quality of life you did not know you had lost. The benefits of oxygen therapy include:
- Breathing easier: Following your treatment plan can reduce feelings of breathlessness throughout the day.
- Being more active: From exercising to just getting out of the house to run errands, oxygen therapy may help you return to the activities you enjoy.
- Increasing your energy: Fatigue is one of the common symptoms of low oxygen levels. When your body is receiving the amount of oxygen necessary to function normally, your heart can more easily circulate it throughout your body and this may boost your energy levels.
- Sleeping better: If you have low oxygen levels, it can be difficult to get a good night's sleep. Your practitioner may also determine medically necessity for sleep therapy or supplemental oxygen during the night, depending on your condition.
