Exhibit 2 - How Medicare Pays For Electric Wheelchairs

If you need an electric wheelchair prescribed by your doctor, you may already know that Medicare can help pay for it. Medicare requires (specify name of supplier) to give you the option of either renting or purchasing it. If you decide that purchase is more economical, for example, because you will need the electric wheelchair for a long time, Medicare pays 80 percent of the allowed purchase price in a lump sum amount. You are responsible for the 20 percent coinsurance amounts and, for unassigned claims, the balance between the Medicare allowed amount and the supplier's charge. However, you must elect to purchase the electric wheelchair at the time your medical equipment supplier furnishes you the item. If you elect to rent the electric wheelchair, you are again given the option of purchasing it during your 10th rental month.

If you continue to rent the electric wheelchair for 10 months, Medicare requires (specify name of supplier) to give you the option of converting your rental agreement to a purchase agreement. This means that if you accept this option, you would own the medical equipment. If you accept the purchase option, Medicare continues making rental payments for your equipment for 3 additional rental months. You are responsible for the 20 percent coinsurance amounts and, for unassigned claims, the balance between the Medicare allowed amount and the supplier's charge. After these additional rental payments are made, title to the equipment is transferred to you. You have until (specify the date one month from the date the supplier notifies the patient of this option) to elect the purchase option. If you decide not to elect the purchase option, Medicare continues making rental payments for an additional 5 rental months, a total of 15 months. After a total of 15 rental months have been paid, title to the equipment remains with the medical equipment supplier; however, the supplier may not charge you any additional rental amounts.

In making your decision to rent or purchase the equipment, you should know that for purchased equipment, you are responsible for 20 percent of the service charge each time your equipment is actually serviced and, for unassigned claims, the balance between the Medicare allowed amount and the supplier's charge. However, for equipment that is rented for 15 months, your responsibility for such service is limited to 20 percent coinsurance on a maintenance and servicing fee payable twice per year whether or not the equipment is actually serviced.

Condition to get payment for repair and maintanenance

Reimbursement may be made for expenses incurred by a patient for the rental or purchase of durable medical equipment (DME) for use in his/her home provided that all the conditions in column A below have been met. Column B indicates the action contractors will take to establish that the conditions have been met.

b) Separate charges for repair, maintenance and delivery

(b) Repairs - only if DME is being purchased or is already owned by patient and repair is necessary to make the equipment serviceable. Medicare pays the least expensive alternative.

Maintenance - only if the equipment is being purchased, or is already owned by the patient, and if the maintenance is extensive amounting to repairs, i.e., requiring the services of skilled technicians. (Contractors deny claims for routine maintenance and periodic servicing, e.g., testing, cleaning, checking, oiling, etc.)


Delivery - of rented or purchased equipment is covered, but the related payment is included in the fee schedule for the item. Additional payment may be made at the discretion of the contractor in special circumstances


(c) Separate charges for disposable supplies, e.g., oxygen, if essential to the effective use of medically necessary durable medical equipment. Separate charges for replacement of essential accessories such as hoses, tubes, mouthpieces, etc., only if the beneficiary owns or is purchasing durable medical equipment (

c) Claim must indicate that:
• The patient has the DME for which the supply is intended;
• The DME continues to be medically necessary; and
• The items are readily identifiable as the type customarily used with such equipment.
NOTE: If the quantity of accessories and/or supplies included in a claim seems excessive or if claims for such items are received from the same claimant with undue frequency,

Prosthetic Devices - Coverage Definition

Prosthetic devices (other than dental) are covered under Part B as a medical or other health service (§1861(s)(8) of the Act) and are devices that replace all or part of an internal body organ or replace all or part of the function of a permanently inoperative or malfunctioning internal body organ. Replacements or repairs of such devices are covered when furnished incident to physicians' services or on a physician's orders.

For detailed coverage requirements (including definitions and discussion) associated with the following prosthetic device terms and circumstances see the Medicare Benefit Policy Manual, Chapter 15:

• "Test of Permanence"

• "Prosthetic Lences"

• "Intraocular Lenses (IOLs)"

• "Supplies, Adjustments, Repairs and Replacements"

For coverage information on specific situations and prosthetic devices, see the Medicare National Coverage Determinations Manual.


 Prosthetics and Orthotics (Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes) - Coverage 

Definition



These appliances are covered under Part B as a medical or other health service (§1861(s)(9) of the Act) when furnished incident to physicians' services or on a physician's order. A brace includes rigid and semi-rigid devices that are used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body.
For detailed coverage requirements (including definitions and discussion) associated with the following terms and circumstances see the Medicare Benefit Policy Manual, Chapter 15:

"Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes"

"Adjustments and Replacement of Artificial Limbs"

Medicare covered DME CPT codes list 3

HCPCS Code Description

E0783 Infusion pump, implantable, Programmable
E0784 External ambulatory infusion pump
E0786 Implantable programmable infusion pump, replacement
E0840 Tract frame attach to headboard, cervical traction
E0849 Traction equipment cervical, free-standing stand/frame, pneumatic, applying traction force to other than mandible
E0850 Traction stand, free standing, cervical traction
E0855 Cervical traction equipment not requiring additional stand or frame
E0856 Cervical traction device, cervical collar with inflatable air bladder
E0958 Manual wheelchair accessory, one-arm drive attachment
E0959 Manual wheelchair accessory-adapter for Amputee
E0960 Manual wheelchair accessory, shoulder harness/strap
E0961 Manual wheelchair accessory wheel lock brake extension handle
E0966 Manual wheelchair accessory, headrest extension
E0967 Manual wheelchair accessory, hand rim with projections
E0968 Commode seat, wheelchair
E0969 Narrowing device wheelchair
E0971 Manual wheelchair accessory anti-tipping device
E0973 Manual wheelchair accessory, adjustable height, detachable armrest
E0974 Manual wheelchair accessory anti-rollback device
E0978 Manual wheelchair accessory positioning belt/safety belt/ pelvic strap
E0980 Manual wheelchair accessory safety vest
E0981 Manual wheelchair accessory Seat upholstery, replacement only
E0982 Manual wheelchair accessory, back upholstery, replacement only
E0983 Manual wheelchair accessory power add on to convert manual wheelchair to motorized wheelchair, joystick control
E0984 Manual wheelchair accessory power add on to convert manual wheelchair to motorized wheelchair, Tiller control
E0985 Wheelchair accessory, seat lift mechanism
E0986 Manual wheelchair accessory, push activated power assist
E0990 Manual wheelchair accessory, elevating leg rest
E0992 Manual wheelchair accessory, elevating leg rest solid seat insert
E0994 Arm rest
E1014 Reclining back, addition to pediatric size wheelchair
E1015 Shock absorber for manual wheelchair
E1020 Residual limb support system for wheelchair
E1028 Wheelchair accessory, manual swing away, retractable or removable mounting hardware for joystick, other control interface or positioning
accessory
E1029 Wheelchair accessory, ventilator tray
E1030 Wheelchair accessory, ventilator tray, gimbaled
E1031 Rollabout chair, any and all types with castors 5" or greater
E1035 Multi-positional patient transfer system with integrated seat operated by care giver
E1036 Patient transfer system
E1037 Transport chair, pediatric size
E1038 Transport chair, adult size up to 300lb
E1039 Transport chair, adult size heavy duty >300lb
E1161 Manual Adult size wheelchair includes tilt in space
E1227 Special height arm for wheelchair
E1228 Special back height for wheelchair
E1232 Wheelchair, pediatric size, tilt-in-space, folding, adjustable with seating system
E1233 Wheelchair, pediatric size, tilt-in-space, folding, adjustable without seating system
E1234 Wheelchair, pediatric size, tilt-in-space, folding, adjustable without seating system
E1235 Wheelchair, pediatric size, rigid, adjustable, with seating system
E1236 Wheelchair, pediatric size, folding, adjustable, with seating system
E1237 Wheelchair, pediatric size, rigid, adjustable, without seating system
E1238 Wheelchair, pediatric size, folding, adjustable, without seating system
E1296 Special sized wheelchair seat height
E1297 Special sized wheelchair seat depth by upholstery
E1298 Special sized wheelchair seat depth and/or width by construction
E1310 Whirlpool non-portable
E2502 Speech Generating Devices prerecord messages between 8 and 20 Minutes
E2506 Speech Generating Devices prerecord messages over 40 minutes
E2508 Speech Generating Devices message through spelling, manual type
E2510 Speech Generating Devices synthesized with multiple message methods
E2227 Rigid pediatric wheelchair adjustable
K0001 Standard wheelchair
K0002 Standard hemi (low seat) wheelchair
K0003 Lightweight wheelchair
K0004 High strength ltwt wheelchair
K0005 Ultra Lightweight wheelchair
K0006 Heavy duty wheelchair
K0007 Extra heavy duty wheelchair
K0009 Other manual wheelchair/base
K0606 AED garment with electronic analysis
K0730 Controlled dose inhalation drug delivery system

Medicare covered DME CPT codes list 1

DME List of Specified Covered Items – Revised March 26, 2015

HCPCS  Code Description
E0185 Gel or gel-like pressure mattress pad
E0188 Synthetic sheepskin pad
E0189 Lamb's wool sheepskin pad
E0194 Air fluidized bed
E0197 Air pressure pad for mattress standard length and width
E0198 Water pressure pad for mattress standard length and width
E0199 Dry pressure pad for mattress standard length and width
E0250 Hospital bed fixed height with any type of side rails, mattress
E0251 Hospital bed fixed height with any type side rails without mattress
E0255 Hospital bed variable height with any type side rails with mattress
E0256 Hospital bed variable height with any type side rails without mattress
E0260 Hospital bed semi-electric (Head and foot adjustment) with any type side rails with mattress
E0261 Hospital bed semi-electric (head and foot adjustment) with any type side rails without mattress
E0265 Hospital bed total electric (head, foot and height adjustments) with any type side rails with mattress
E0266 Hospital bed total electric (head, foot and height adjustments) with any type side rails without mattress
E0290 Hospital bed fixed height without rails with mattress
E0291 Hospital bed fixed height without rail without mattress
E0292 Hospital bed variable height without rail without mattress
E0293 Hospital bed variable height without rail with mattress
E0294 Hospital bed semi-electric (head and foot adjustment) without rail with mattress
E0295 Hospital bed semi-electric (head and foot adjustment) without rail without mattress
E0296 Hospital bed total electric (head, foot and height adjustments) without rail with mattress
E0297 Hospital bed total electric (head, foot and height adjustments) without rail without mattress
E0300 Pediatric crib, hospital grade, fully enclosed
E0301 Hospital bed Heavy Duty extra wide, with weight capacity 350-600 lbs with any type of rail, without mattress
E0302 Hospital bed Heavy Duty extra wide, with weight capacity greater than 600 lbs with any type of rail, without mattress
E0303 Hospital bed Heavy Duty extra wide, with weight capacity 350-600 lbs with any type of rail, with mattress
E0304 Hospital bed Heavy Duty extra wide, with weight capacity greater than 600 lbs with any type of rail, with mattress
E0424 Stationary compressed gas Oxygen System rental; includes contents, regulator, 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
E0434 Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, content gauge, cannula or
mask, and tubing
E0439 Stationary liquid oxygen system rental, includes container, contents, aregulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
E0441 Oxygen contents, gaseous (1 months supply)
E0442 Oxygen contents, liquid (1 months supply)
E0443 Portable Oxygen contents, gas (1 months supply)

April 2015 ASC X12 837 (electronic healthcare claim) -- CMS edits implementation

Due to the Health Insurance Portability and Accountability Act (HIPAA), change request 8851, and electronic data interchange (EDI), front-end updates, the Centers for Medicare & Medicaid Services has implemented 5010 837P and 837I transaction edits, which will be effective: April 6, 2015.

Added 5010 837P transaction edits -- effective April 6, 2015

Edit Reference number	Change
X222.226.2300.HI01-2.130	277CA edit added to reject claims if the diagnosis code is duplicated within the HI segment
X222.242.2300.HI01-2.030	277CA edit added to reject claims if the Condition codes are duplicated within the HI segment
X222.351.2400.SV101-3.030	277CA edit added to reject claims if the Modifier codes are duplicated within the same SV1 segment
X222.480.2430.SVD03-3.020	277CA edit added to reject claims if the Modifier codes are duplicated within the same SVD segment
Added 5010 837I transaction edits -- effective April 6, 2015
Edit Reference	Change
X223.189.2300.HI01-2.050	277CA edit added to reject claims if the Patient Reason for Visit Code in the HI segment is duplicated
X223.193.2300.HI01-2.060	277CA edit added to reject claims if the External Cause of Injury Code in the HI segment is duplicated
X223.220.2300.HI01-2.050	277CA edit added to reject claims if the Diagnosis Code in the HI segment is duplicated
X223.294.2300.HI01-2.020	277CA edit added to reject claims if the Condition Code in the HI segment is duplicated
X223.424.2400.SV202-3.020	277CA edit added to reject claims if the Procedure Code Modifier in SV202 within the same detail service line is duplicated.
X223.476.2430.SVD03-3.020	277CA edit added to reject claims if the Modifier codes are duplicated within the same SVD segment
X223.304.2300.HI02.020	edit added to ensure treatment codes are not duplicated
Updated 5010 837I transaction edits -- effective April 6, 2015
Edit Reference	Change
X223.184.2300.HI.013	revised
X223.184.2300.HI.016	revised
X223.366.2320.AMT.020	999 edit revised to only allow one iteration of the loop/segment.
X223.367.2320.OI.020	999 edit revised to only allow one iteration of the loop/segment.
X223.369.2320.MIA.020	999 edit revised to only allow one iteration of the loop/segment.
X223.374.2320.MOA.020	999 edit revised to only allow one iteration of the loop/segment.
X223.377.2330A.NM1.020	999 edit revised to only allow one iteration of the loop/segment.
X223.380.2330A.N3.020	999 edit revised to only allow one iteration of the loop/segment.
X223A2.21.2330A.N4.020	999 edit revised to only allow one iteration of the loop/segment.
X223.384.2330B.NM1.020	999 edit revised to only allow one iteration of the loop/segment.
X223.386.2330B.N3.020	999 edit revised to only allow one iteration of the loop/segment.
X223A2.22.2330B.N4.020	999 edit revised to only allow one iteration of the loop/segment.
X223.389.2330B.DTP.020	999 edit revised to only allow one iteration of the loop/segment.
X223.392.2330B.REF.020	999 edit revised to only allow one iteration of the loop/segment.
X223.393.2330B.REF.020	999 edit revised to only allow one iteration of the loop/segment.
X223.394.2330B.REF.020	999 edit revised to only allow one iteration of the loop/segment.
X223.395.2330B.REF.020	999 edit revised to only allow one iteration of the loop/segment.
X223.476.2430.SVD.010	999 edit revised to only allow one iteration of the loop/segment.
X223.486.2430.DTP.020	999 edit revised to only allow one iteration of the loop/segment.
X223.487.2430.AMT.020	999 edit revised to only allow one iteration of the loop/segment.
X223.184.2300.HI.014	revised comment to: Only ICD-9 qualifiers are allowed on production claims prior to the effective date of ICD-10.  The purpose of this edit is to prevent ICD-10 codes from coming into the system on production claims prior to ICD-10 being in effect.
X223.239.2300.HI01-1.011	revised comment to: Only ICD-9 qualifiers are allowed on production claims prior to the effective date of ICD-10.  The purpose of this edit is to prevent ICD-10 codes from coming into the system on production claims prior to ICD-10 being in effect.
Deactivated 5010 837I transaction edits -- effective April 6, 2015
Edit Reference	Change
X223.354.2320.SBR.010	edit deactivated
X223.239.2300.HI01-1.013	deactivated
X223.239.2300.HI01-1.016	deactivated

Update to Medicare deductible, coinsurance, and premium rates for 2015

Effective date January 1, 2015
Implementation date: January 5, 2015

SummaryThe Centers for Medicare & Medicaid Services (CMS) issued the 2015 deductibles, coinsurance, and premium rates for beneficiaries covered through the Medicare fee for service program. The 2015 deductible, coinsurance and base premium rates are:

2015 Part A - Hospital insurance
Deductible: $1,260.00
Coinsurance
• • $315 a day for 61st-90th day
• • $630 a day for 91st-150th day (lifetime reserve days)
• • $157.50 a day for 21st-100th day (skilled nursing facility coinsurance)
Base premium (BP): $407 a month
• BP with 10 percent surcharge: $447.70 a month
• BP with 45 percent reduction: $224 a month (for those who have 30-39 quarters of coverage)
• BP with 45 percent reduction and 10 percent surcharge: $246.40 a month

2015 Part B - Supplementary medical insurance (SMI)
Under Part B of the Medicare supplementary medical insurance (SMI) program, enrollees are subject to a monthly premium. Most SMI services are subject to an annual deductible and coinsurance (percent of costs that the enrollee must pay), which are set by statute.
Standard Premium: $104.90 a month
Deductible: $147 a year
Pro Rata Data Amount
• $114.99 1st month
• $32.01 2nd month
Coinsurance: 20 percent

Medicare coverage Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes

These appliances are covered under Part B when furnished incident to physicians’ services or on a physician’s order. A brace includes rigid and semi-rigid devices which are used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body. Elastic stockings, garter belts, and similar devices do not come within the scope of the definition of a brace. Back braces include, but are not limited to, special corsets, e.g., sacroiliac, sacrolumbar, dorsolumbar corsets, and belts. A terminal device (e.g., hand or hook) is covered under this provision whether an artificial limb is required by the patient. Stump stockings and harnesses (including replacements) are also covered when these appliances are essential to the effective use of the artificial limb.

Adjustments to an artificial limb or other appliance required by wear or by a change in the patient’s condition are covered when ordered by a physician.

Adjustments, repairs and replacements are covered even when the item had been in use before the user enrolled in Part B of the program so long as the device continues to be medically required.


Prosthetic Lenses
The term “internal body organ” includes the lens of an eye. Prostheses replacing the lens of an eye include post-surgical lenses customarily used during convalescence from eye surgery in which the lens of the eye was removed. In addition, permanent lenses are also covered when required by an individual lacking the organic lens of the eye because of surgical removal or congenital absence. Prosthetic lenses obtained on or after the beneficiary’s date of entitlement to supplementary medical insurance benefits may be covered even though the surgical removal of the crystalline lens occurred before entitlement.

Durable Medical Equipment - Medicare General guidelines

Expenses incurred by a beneficiary for the rental or purchases of durable medical equipment (DME) are reimbursable if the following three requirements are met:

• The equipment meets the definition of DME (§110.1);
• The equipment is necessary and reasonable for the treatment of the patient’s illness or injury or to improve the functioning of his or her malformed body member (§110.1); and
• The equipment is used in the patient’s home.

The decision whether to rent or purchase an item of equipment generally resides with the beneficiary, but the decision on how to pay rests with CMS. For some DME, program payment policy calls for lump sum payments and in others for periodic payment. Where covered DME is furnished to a beneficiary by a supplier of services other than a provider of services, the DMERC makes the reimbursement. If a provider of services furnishes the equipment, the intermediary makes the reimbursement. The payment method is identified in the annual fee schedule update furnished by CMS.

The CMS issues quarterly updates to a fee schedule file that contains rates by HCPCS code and also identifies the classification of the HCPCS code within the following categories.



Category Code Definition
IN  Inexpensive and Other Routinely Purchased Items
FS Frequently Serviced Items
CR Capped Rental Items
OX Oxygen and Oxygen Equipment
OS Ostomy, Tracheostomy & Urological Items
SD Surgical Dressings
PO Prosthetics & Orthotics
SU Supplies
TE Transcutaneous Electrical Nerve Stimulators



The DMERCs, carriers, and intermediaries, where appropriate, use the CMS files to determine payment rules. See the Medicare Claims Processing Manual, Chapter 20, “Durable Medical Equipment, Surgical Dressings and Casts, Orthotics and Artificial Limbs, and Prosthetic Devices,” for a detailed description of payment rules for each classification.

Payment may also be made for repairs, maintenance, and delivery of equipment and for expendable and nonreusable items essential to the effective use of the equipment subject to the conditions

DME billing - Medicare redetermination form

Medicare Redetermination Request Form

Medicare rules for oxygen equipment

New Rules for How Medicare Pays Suppliers for Oxygen Equipment

Changes in law require Medicare to change the way it pays suppliers for oxygen equipment and supplies. You will still be able to get your oxygen equipment.However, you should know about the new rules that start January 1, 2009.Previously, the law stated that you would own the oxygen equipment after you rented it for 36 months. Under the new law, the rental payments will end after 36months, but the supplier continues to own the equipment. The new law then requires your supplier to provide the oxygen equipment and related supplies for 2additional years (5 years total), as long as oxygen is still medically necessary.

How does Medicare pay for oxygen equipment and related supplies and what do I pay?

The monthly rental payments to the supplier cover not only your oxygen equipment, but also any supplies and accessories such as tubing or a mouthpiece,oxygen contents, maintenance, servicing and repairs. Medicare pays 80% of the rental amount, and the person with Medicare is responsible for any unpaid Part B deductible, and the remaining 20% of the rental amount.

What happens with my oxygen equipment and related services after the 36 months of rental payments?

Your supplier has been paid over 36 months for furnishing your oxygen and oxygen equipment for up to 5 years, and your supplier is required to continue to maintain the oxygen equipment (in good working order) and furnish the equipment and any necessary supplies and accessories, as long as you need it until the 5 year period ends. The supplier can’t charge you for performing these services.If you use oxygen tanks or cylinders that need delivery of gaseous or liquid oxygen contents, Medicare will continue to pay each month for the delivery of contents after the 36-month rental period. The supplier that delivers this equipment to you in the last month of the 36-month rental period must provide these items, as long as you medically need it, up to 5 years.

Will Medicare pay for any maintenance and servicing after the 36-month period ends?

If you use an oxygen concentrator or trans filling equipment (a machine that fills your portable tanks in your home), for 2009 only, Medicare will pay for routine maintenance and servicing visits every 6 months starting 6 months after the end of the 36-month rental period.


Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act §1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.

Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee For Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.

For an item to be covered by Medicare, a detailed written order (DWO) must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as not reasonable and necessary.

For some items in this policy to be covered by Medicare, a written order prior to delivery (WOPD) is required. Refer to the DOCUMENTATION REQUIREMENTS section of this LCD and to the NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section of the related Policy Article for information about WOPD prescription requirements

Home oxygen is covered only when both the reasonable and necessary criteria discussed below and the statutory criteria discussed in the Policy Article are met. Refer to the Policy Article for additional information on statutory payment policy requirements.

Home oxygen therapy is reasonable and necessary only if all of the following conditions are met:
The treating physician has determined that the beneficiary has a severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy, and

The beneficiary's blood gas study meets the criteria stated below, and

The qualifying blood gas study was performed by a physician or by a qualified provider or supplier of laboratory services, and

The qualifying blood gas study was obtained under the following conditions:

If the qualifying blood gas study is 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, or
If the qualifying blood gas study is not performed during an inpatient hospital stay, the reported test must be performed while the beneficiary is in a chronic stable state – i.e., not during a period of acute illness or an exacerbation of their underlying disease, and
Alternative treatment measures have been tried or considered and deemed clinically ineffective.
In this policy, the term blood gas study refers to either an oximetry test or an arterial blood gas test.

Group I criteria include any of the following:
An arterial PO 2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent taken at rest (awake), or

An arterial PO 2 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 beneficiary who demonstrates an arterial PO 2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89 percent while awake, or

A decrease in arterial PO 2 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 PO 2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent, taken during exercise for a beneficiary who demonstrates an arterial PO 2 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 beneficiary was breathing room air.
Initial coverage for beneficiaries meeting Group I criteria is limited to 12 months or the physician-specified length of need, whichever is shorter. (Refer to the Certification section for information on recertification.)

Group II criteria include the presence of
An arterial PO 2 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

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" pulmonale on EKG (P wave greater than 3 mm in standard leads II, III, or AVF), or

Erythrocythemia with a hematocrit greater than 56 percent.

Initial coverage for beneficiaries meeting Group II criteria is limited to 3 months or the physician specified length of need, whichever is shorter. (Refer to the Certification section for information on recertification.) Group III includes beneficiaries with arterial PO 2 levels at or above 60 mm Hg or arterial blood oxygen saturations at or above 90 percent. For these beneficiaries there is a rebuttable presumption of non-coverage.

If all of the coverage conditions specified above are not met, the oxygen therapy will be denied as not reasonable and necessary. Oxygen therapy will also be denied as not reasonable and necessary if any of the following conditions are present:
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

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 PO 2 will improve the oxygenation of tissues with impaired circulation.

Terminal illnesses that do not affect the respiratory system
LONG TERM OXYGEN THERAPY CLINICAL (LTOT) TRIALS

Oxygen and oxygen equipment is covered for beneficiaries who are enrolled subjects in clinical trials approved by CMS and sponsored by the National Heart, Lung, and Blood Institute (NHLBI) and who have an arterial PO 2 from 56 to 65 mm Hg or an oxygen saturation at or above 89 percent. The additional Group 2 coverage criteria do not apply to these beneficiaries.

Refer to the APPENDICES section of this policy for additional information about approved clinical trials.

CLUSTER HEADACHES (CH):

Only a stationary gaseous oxygen system (E0424) and related contents (E0441) are covered for the treatment of cluster headaches for beneficiaries enrolled in a clinical trial approved by CMS which are in compliance with the requirements described in the CMS National Coverage Determination Manual (Internet Only Manual 100-03) §240.2.2 for dates of service on or after 01/04/2011. This section states, in part:

Only those beneficiaries diagnosed with the condition of cluster headache are eligible for participation in a clinical study. CMS adopts the diagnostic criteria used by the International Headache Society to form a definitive diagnosis of CH. Therefore, the home use of oxygen to treat CH is covered by Medicare only when furnished to Medicare beneficiaries who have had at least five severe to very severe unilateral headache attacks lasting 15-180 minutes when untreated. (Intensity of pain: Degree of pain usually expressed in terms of its functional consequence and scored on a verbal 5-point scale: 0=no pain; 1=mild pain, does not interfere with usual activities; 2=moderate pain, inhibits but does not wholly prevent usual activities; 3=severe pain, prevents all activities; 4=very severe pain. It may also be expressed on a visual analogue scale.)

The headaches must be accompanied by at least one of the following findings:
Ipsilateral conjunctival injection and/or lacrimation; or

Ipsilateral nasal congestion and/or rhinorrhea; or

Ipsilateral eyelid edema; or

Ipsilateral forehead and facial sweating; or

Ipsilateral miosis and/or ptosis; or

A sense of restlessness or agitation
Claims for oxygen equipment not meeting the criteria above will be denied as not reasonable and necessary.

Claims for stationary oxygen equipment other than E0424 and all portable oxygen equipment used for cluster headaches will be denied as not reasonable and necessary.

Claims for E0424 and E0441 used to treat cluster headaches follow the same payment rules for all other covered oxygen equipment. Refer to the related Policy Article for information on statutory payment rules and coding guidelines to be used for these claims.

Refer to the APPENDICES section of this policy for additional information about approved clinical trials.

Reference Diagnosis Codes that Support Medical Necessity section for applicable diagnoses.

TESTING SPECIFICATIONS:

General

For purposes of this policy:

“Blood gas study” shall refer to both arterial blood gas (ABG) studies and pulse oximetry

“Oximetry” shall refer to routine or “spot” pulse oximetry

“Overnight oximetry” shall refer to stand-alone pulse oximetry continuously recorded overnight. It does not include oximetry results done as part of other overnight testing such as polysomnography or home sleep testing.
Refer to the Positive Airway Pressure Devises used for the Treatment of Obstructive Sleep Apnea policy for information on sleep tests used for the diagnosis of sleep apnea.

The qualifying blood gas study must be one that complies with the Fiscal Intermediary, Local Carrier, or A/B Medicare Administrative Contractor (MAC) policy on the standards for conducting the test and is covered under Medicare Part A or Part B. This includes a requirement that the test be performed by a provider who is qualified to bill Medicare for the test – i.e., a Part A provider, a laboratory, an Independent Diagnostic Testing Facility (IDTF), or a physician. A supplier is not considered a qualified provider or a qualified laboratory for purposes of this policy. Blood gas studies performed by a supplier are not acceptable. In addition, the qualifying blood gas study may not be paid for by any supplier. These prohibitions do not extend to blood gas studies performed by a hospital certified to do such tests.

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

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

All oxygen qualification testing must be performed in-person by a physician or other medical professional qualified to conduct oximetry testing. With the exception of overnight oximetry (see below), unsupervised or remotely supervised home testing does not qualify as a valid test for purposes of Medicare reimbursement of home oxygen and oxygen equipment.

Exercise testing

When oxygen is covered based on an oximetry study obtained during exercise, there must be documentation of three (3) oximetry studies in the beneficiary’s medical record. (1) Testing at rest without oxygen, (2) testing during exercise without oxygen, and (3) testing during exercise with oxygen applied (to demonstrate the improvement of the hypoxemia) are required. All 3 tests must be performed within the same testing session. Exercise testing must be performed in-person by a physician or other medical professional qualified to conduct exercise oximetry testing. Unsupervised or remotely supervised home exercise testing does not qualify as a valid test for purposes of Medicare reimbursement of home oxygen and oxygen equipment. Only the testing during exercise without oxygen is used for qualification and reported on the CMN. The other two results do not have to be routinely submitted but must be available on request.

Oximetry obtained after exercise while resting, sometimes referred to as “recovery” testing, is not part of the three required test elements and is not valid for determining eligibility for oxygen coverage.

Overnight Oximetry Studies:

Overnight sleep oximetry may be performed in a facility or at home. For home overnight oximetry studies, the oximeter provided to the beneficiary must be tamper-proof and must have the capability to download data that allows documentation of the duration of oxygen desaturation below a specified value.

For all the overnight oximetry criteria described above, the 5 minutes does not have to be continuous. Baseline saturation is defined as the mean saturation level during the duration of the test. For purposes of meeting criterion 3 described in Group I above there must be a minimum of 2 hours test time recorded for sleep oximetry. The result must reach a qualifying test value otherwise the Group III presumption of non-coverage applies.

Home overnight oximetry is limited solely to stand-alone overnight pulse oximetry performed in the beneficiary’s home under the conditions specified below. Overnight oximetry performed as part of home sleep testing or as part of any other home testing is not considered to be eligible under this provision to be used for qualification for reimbursement of home oxygen and oxygen equipment even if the testing was performed in compliance with the requirements of this section.

Beneficiaries may self-administer home based overnight oximetry tests under the direction of a Medicare-enrolled Independent Diagnostic Testing Facility (IDTF). A DME supplier or another shipping entity may deliver a pulse oximetry test unit and related technology to a beneficiary’s home under the following circumstances:
The beneficiary’s treating physician has contacted the IDTF to order an overnight pulse oximetry test before the test is performed.

The test is performed under the direction and/or instruction of a Medicare-approved IDTF. Because it is the beneficiary who self-administers this test, the IDTF must provide clear written instructions to the beneficiary on proper operation of the test equipment and must include access to the IDTF in order to address other concerns that may arise. The DME supplier may not create this written instruction, provide verbal instructions, answer questions from the beneficiary, apply or demonstrate the application of the testing equipment to the beneficiary, or otherwise participate in the conduct of the test.

The test unit is sealed and tamper-proof such that test results cannot be accessed by anyone other than the IDTF which is responsible for transmitting a test report to the treating physician. The DME supplier may use related technology to download test results from the testing unit and transmit those results to the IDTF. In no case may the DME supplier access or manipulate the test results in any form.
The IDTF must send the test results to the physician. The IDTF may send the test results to the supplier if the supplier is currently providing or has an order to provide oxygen or other respiratory services to the beneficiary or if the beneficiary has signed a release permitting the supplier to receive the report.

Oximetry test results obtained through a similar process as described for home overnight oximetry (see above) while the beneficiary is awake, either at rest or with exercise, may not be used for purposes of qualifying the beneficiary for home oxygen therapy.

Overnight oximetry does not include oximetry obtained during polysomnography or other sleep testing for sleep apnea, regardless of the location the testing was performed. See below for information on sleep testing that may be used to qualify for oxygen coverage.

Obstructive Sleep Apnea (OSA), Polysomnography and Home Sleep Tests:

Some beneficiaries may require the simultaneous use of home oxygen therapy with a PAP device. To be considered for simultaneous coverage, all requirements in the Coverage Indications, Limitations and/or Medical Necessity for both the Oxygen and Oxygen Equipment and Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea LCDs must be met. Consequently, in addition to this Oxygen LCD, suppliers should refer to the Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea LCD and related Policy Article for additional coverage, coding and documentation requirements.

Coverage of home oxygen therapy requires that the beneficiary be tested in the “chronic stable state.” Chronic stable state is a requirement of the National Coverage Determination (CMS Internet-only Manual, Pub. 100-03, Section 240.2) and is one of the key criteria when determining coverage of home oxygen therapy. The NCD defines chronic stable state as “…not during a period of an acute illness or an exacerbation of their underlying disease.” Based on this NCD definition, all co-existing diseases or conditions that can cause hypoxia must be treated and the beneficiary must be in a chronic stable state before oxygen therapy is considered eligible for payment. In addition, the beneficiary must have a severe lung disease, such as chronic obstructive pulmonary disease, diffuse interstitial lung disease, cystic fibrosis, bronchiectasis, widespread pulmonary neoplasm, or hypoxia-related symptoms or findings that might be expected to improve with oxygen therapy. In the case of OSA, it is required that the OSA be appropriately and sufficiently treated such that the beneficiary is in the chronic stable state before oxygen saturation results obtained during sleep testing are considered qualifying for oxygen therapy (see PAP LCD for additional information).

For beneficiaries with 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.

For beneficiaries with OSA, a qualifying oxygen saturation test may only occur during a titration polysomnographic study (either split night or stand-alone). The titration PSG is one in which all of the following criteria are met:

The titration is conducted over a minimum of two (2) hours; and

During titration:

The AHI/RDI is reduced to less than or equal to an average of ten (10) events per hour; or

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
Nocturnal oximetry conducted for the purpose for oxygen reimbursement qualification may only be performed after optimal PAP settings have been determined and the beneficiary is using the PAP device at those settings; and

The nocturnal oximetry conducted during the PSG demonstrates an oxygen saturation = 88% for 5 minutes total (which need not be continuous)
If all of the above criteria are met, for the purposes of a qualifying oxygen saturation test, the beneficiary is considered to be in the “chronic stable state.” To be eligible for Medicare coverage and payment for home oxygen therapy for concurrent use with PAP therapy, in addition to being in the chronic stable state, the beneficiary must meet all other coverage requirements for oxygen therapy. Beneficiaries that qualify for oxygen therapy based on testing conducted only during the course of a sleep test are eligible only for reimbursement of stationary equipment.

Overnight oximetry performed as part of home sleep testing or as part of any other home testing is not considered as eligible to be used for qualification for reimbursement of home oxygen and oxygen equipment (see overnight oximetry section above for additional information).

Claims for oxygen equipment and supplies for beneficiaries who do not meet the coverage requirements for home oxygen therapy will be denied as not reasonable and necessary.

CERTIFICATION: 

An Initial, Recertification, or Revised CMN must be obtained and submitted in the situations described below. The Initial Date, Recertification Date, and Revised Date specified below refer to the dates reported in Section A of the CMN.

Initial CMN is required:
With the first claim for home oxygen, (even if the beneficiary was on oxygen prior to Medicare eligibility or oxygen was initially covered by a Medicare HMO).

During the first 36 months of the rental period, when there has been a change in the beneficiary’s condition that has caused a break in medical necessity of at least 60 days plus whatever days remain in the rental month during which the need for oxygen ended. Refer to the Policy Article NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES for additional information.

When the equipment is replaced because the reasonable useful lifetime of prior equipment has been reached.

When the equipment is replaced because of irreparable damage, theft, or loss of the originally dispensed equipment.

Irreparable damage refers to a specific accident or to a natural disaster [e.g., fire, flood]

Irreparable damage does not refer to wear and tear over time

Testing and Visit Requirements:

Initial CMN for situations 1 and 2
The blood gas study must be the most recent study obtained within 30 days prior to the Initial Date.

For situation 1, there is an exception to the 30-day test requirement for beneficiaries who were started on oxygen while enrolled in a Medicare HMO and transition to fee-for-service Medicare. For those beneficiaries, the blood gas study does not have to be obtained 30 days prior to the Initial Date, but must be the most recent qualifying test obtained while in the HMO.

The beneficiary must be seen and evaluated by the treating physician within 30 days prior to the date of Initial Certification.
Initial CMN for scenarios 3 and 4 (replacement equipment)
Repeat blood gas testing is not required. Enter the most recent qualifying value and test date. This test does not have to be within 30 days prior to the Initial Date. It could be the test result reported on the most recent prior CMN.

There is no requirement for a physician visit that is specifically related to the completion of the CMN for replacement equipment.
Recertification CMN is required:
12 months after Initial Certification, (i.e., with the thirteenth month’s claim) for Group I

3 months after Initial Certification, (i.e., with the fourth month’s claim) for Group II
Testing and Visit Requirements:

Recertification following initial certification situations 1 and 2
For beneficiaries initially meeting Group I criteria, the most recent qualifying blood gas study prior to the thirteenth month of therapy must be reported on the Recertification CMN.
For beneficiaries initially meeting Group II criteria, the most recent blood gas study that was performed between the 61st and 90th day following Initial Certification must be reported on the Recertification CMN. If a qualifying test is not obtained between the 61st and 90th day of home oxygen therapy but the beneficiary continues to use oxygen and a test is obtained at a later date, if that test meets Group I or II criteria, coverage would resume beginning with the date of that test.
For beneficiaries initially meeting group I or II criteria, the beneficiary must be seen and re-evaluated by the treating physician within 90 days prior to the date of any Recertification. If the physician visit is not obtained within the 90-day window but the beneficiary continues to use oxygen and the visit is obtained at a later date, coverage would resume beginning with the date of that visit.
Recertification following initial situations 3 and 4 (replacement equipment)
Repeat testing is not required. Enter the most recent qualifying value and test date. This test does not have to be within 30 days prior to the Initial Date. It could be the test result reported on the most recent prior CMN.

There is no requirement for a physician visit that is specifically related to the completion of the CMN for replacement equipment.
Revised CMN is required:
When the prescribed maximum flow rate changes from one of the following categories to another:

Less than 1 LPM,

1-4 LPM,

Greater than 4 LPM
If the change is from category (a) or (b) to category (c), a repeat blood gas study with the beneficiary on 4 LPM must be performed.
When the length of need expires – if the physician specified less than lifetime length of need on the most recent CMN

When a portable oxygen system is added subsequent to Initial Certification of a stationary system

When a stationary system is added subsequent to Initial Certification of a portable system

When there is a new treating physician but the oxygen order is the same

If there is a new supplier and that supplier does not have the prior CMN
Submission of a Revised CMN does not change the Recertification schedule specified above.

If the indications for a Revised CMN are met at the same time that a Recertification CMN is due, file the CMN as a Recertification CMN.

Testing and Visit Requirements:

None of the Revised Certification situations (7-12) require a physician visit.

Revised Certification situations 7 and 8
The blood gas study must be the most recent study obtained within 30 days prior to the Initial Date.

Revised Certification situation 9
There is no requirement for a repeat blood gas study unless the initial qualifying study was performed during sleep, in which case a repeat blood gas study must be performed while the beneficiary is at rest (awake) or during exercise within 30 days prior to the Revised Date.

Revised Certifications situations 10-12
No blood gas study is required
For situations 11 and 12, the revised certification does NOT have to be submitted with the claim.
General:

Beneficiaries do not change group classification going from an initial certification to a recertification based upon changes in blood oxygen testing results. For example: A beneficiary initially qualifies for group II with an 89% oximetry value. At the 3-month retest a result of 87% is obtained. Despite the group I retesting value, the beneficiary remains in group II. There is no reclassification to group I. Further recertification is not required unless:
A non-qualifying test result is obtained at the time of recertification but the beneficiary later obtains a qualifying test result; or,

The specified length of need (LON) is reached.

Generally only one recertification is required regardless of group classification unless the LON specified on the recertification CMN is some value other than 99 (indicating lifetime). If other than lifetime is specified the certification will expire when the specified LON time period elapses. A recertification will be required to continue coverage.

Recertification is required to be completed on or prior to the end of the initial certification period. If timely recertification is not completed by the end of the initial certification period, reimbursement ends until the recertification is completed. At such time that the recertification requirements are met, payment will resume at the month in the rental cycle where the rental was stopped due to the expiration of the initial certification. A new, initial rental cycle does not begin when the recertification requirements are met.

A completed and signed Certificate of Medical Necessity (CMN) is required to receive payment for oxygen. Claims submitted without a valid CMN will be denied as not reasonable and necessary.

PORTABLE OXYGEN SYSTEMS:

A portable oxygen system is covered if the beneficiary is mobile within the home and the qualifying blood gas study was performed while at rest (awake) or during exercise. If the only qualifying blood gas study was performed during sleep, portable oxygen will be denied as not reasonable and necessary.

If coverage criteria are met, a portable oxygen system is usually separately payable in addition to the stationary system. See exception in the related Policy Article Non-Medical Necessity Coverage and Payment Rules, OXYGEN EQUIPMENT, Initial 36-Months section.

If a portable oxygen system is covered, the supplier must provide whatever quantity of oxygen the beneficiary uses; Medicare’s reimbursement is the same, regardless of the quantity of oxygen dispensed.

LITER FLOW GREATER THAN 4 LPM:

If basic oxygen coverage criteria have been met, a higher allowance for a stationary system for a flow rate of greater than 4 liters per minute (LPM) will be paid only if a blood gas study performed while the beneficiary is on 4 or more LPM meets Group I or II criteria. If a flow rate greater than 4 LPM is billed and the coverage criterion for the higher allowance is not met, payment will be limited to the standard fee schedule allowance. (Refer to related Policy Article for additional information on payment for greater than 4 LPM oxygen.)

MISCELLANEOUS:

Oxygen reimbursement is a bundled payment. All options, supplies and accessories are considered included in the monthly rental payment for oxygen equipment. Oxygen rental is billed using the appropriate code for the provided oxygen equipment. Separately billed options, accessories or supply items will be denied as unbundling.

Emergency or stand-by oxygen systems for beneficiaries who are not regularly using oxygen will be denied as not reasonable and necessary since they are precautionary and not therapeutic in nature.

Topical hyperbaric oxygen chambers (A4575) will be denied as not reasonable and necessary. (IOM 100-03 20.29(B) & (C))

Topical oxygen delivery systems (E0446) will be denied as not reasonable and necessary. (IOM 100-03 20.29(C))

REFILLS OF OXYGEN CONTENTS:

For Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items and supplies provided on a recurring basis, billing must be based on prospective, not retrospective use.

Oxygen contents are reimbursed with a monthly allowance covering all contents necessary for the month. Supply allowances are not subject to the refill monitoring and documentation requirements specified by Medicare Program Integrity Manual section 5.2.6.

All other supplies, e.g. tubing, masks or cannulas, etc., are included in the monthly rental payment. Supplies that are not separately payable are not subject to the refill monitoring and documentation requirements specified by Medicare Program Integrity Manual section 5.2.6.

See the Non-Medical Coverage and Payment Rules section of the related Policy Article for additional information about coverage of oxygen contents.



Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
N/A

Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A

CPT/HCPCS Codes

Group 1 Paragraph: The appearance of a code in this section does not necessarily indicate coverage.

HCPCS MODIFIERS:


EY – No physician or other licensed health care provider order for this item or service

Q0 (Q-zero) - Investigational clinical service provided in a clinical research study that is in an approved clinical research study

QE - Prescribed amount of oxygen is less than 1 liter per minute (LPM)

QF - Prescribed amount of oxygen is greater than 4 liter per minute (LPM) and portable oxygen is prescribed

QG - Prescribed amount of oxygen is greater than 4 liters per minute (LPM)

QH - Oxygen conserving device is being used with an oxygen delivery system


HCPCS CODES:

EQUIPMENT:


Group 1 Codes:
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 ADAPTOR
E0439 STATIONARY LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES CONTAINER, CONTENTS, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, & 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
E0445 OXIMETER DEVICE FOR MEASURING BLOOD OXYGEN LEVELS NON-INVASIVELY
E0446 TOPICAL OXYGEN DELIVERY SYSTEM, NOT OTHERWISE SPECIFIED, INCLUDES ALL SUPPLIES AND ACCESSORIES
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

Group 2 Paragraph: ACCESSORIES:

Group 2 Codes:
A4575 TOPICAL HYPERBARIC OXYGEN CHAMBER, DISPOSABLE
A4606 OXYGEN PROBE FOR USE WITH OXIMETER DEVICE, REPLACEMENT
A4608 TRANSTRACHEAL OXYGEN CATHETER, EACH
A4615 CANNULA, NASAL
A4616 TUBING (OXYGEN), PER FOOT
A4617 MOUTH PIECE
A4619 FACE TENT
A4620 VARIABLE CONCENTRATION MASK
A7525 TRACHEOSTOMY MASK, EACH
A9900 MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE
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

Medicare will pay for rent or purchasing DME ?

How will I know if I can buy durable medical equipment or whether Medicare will only pay for me to rent it?

If your supplier is a Medicare-enrolled supplier, they will know whether Medicare allows you to buy a particular kind of durable medical equipment,or just pays for you to rent it. Medicare pays for most durable medical equipment on a rental basis. Medicare only purchases inexpensive or routinely purchased items, such as canes; power wheelchairs; and, in rare cases, items that must be made specifically for you.


Buying equipment

If you own Medicare-covered durable medical equipment and other devices, Medicare may also cover repairs and replacement parts. Medicare will pay 80% of the Medicare-approved amount for purchase of the item. Medicare will also pay 80% of the Medicare-approved amount (up to the cost of replacing the item)for repairs. You pay the other 20%. Your costs may be higher if the supplier doesn’t accept assignment. Note:The equipment you buy may be replaced if it’s lost,stolen, damaged beyond repair, or used for more than the reasonable useful lifetime of the equipment.

Renting equipment

If you rent durable medical equipment and other devices,Medicare makes monthly payments for use of the equipment. The rules for how long monthly payments continue vary based on the type of equipment. Total rental payments for inexpensive or routinely purchased items are limited to the fee Medicare sets to purchase the item. If you will need these items for more than a few months, you may decide to purchase these items rather than rent them. Monthly payments for frequently serviced items, such as ventilators, are made as long as the equipment is medically necessary. The payment rules for other types of rented equipment,called “capped rental items,” are on page 10. Medicare will pay80% of the Medicare-approved amount each month for use of these items. You pay the other 20% after you pay the Medicare Part B deductible ($135 in 2009).The supplier will pick up the equipment when you no longer need it. Any costs for repairs or replacement parts for the rented equipment are the supplier’s responsibility.

The supplier will also pick up the rented equipment if it needs repairs. You don’t have to bring the rented equipment back to the supplier.

Medicare covered corrective lenses items and patient share of cost

Corrective Lenses items covered by medicare.

What Medicare Covers
•Prosthetic Lenses —Cataract glasses —Conventional glasses and contact lenses after surgery with an intraocular lens —Intraocular lenses An ophthalmologist or an optometrist mustprescribe these items. Important:Only standard frames are covered.Eyeglasses and cataract lenses are covered even ifyou had the surgery before you had Medicare.Payment may be made for lenses for both eyes evenif cataract surgery involved only one eye.

What You Pay
You are covered for one pair ofeyeglasses or contact lenses aftereach cataract surgery with anintraocular lens. You pay 20% ofthe Medicare-approved amountafter you pay the Medicare Part Bdeductible for the year ($135 in2009). Medicare pays the other80%. Costs may be different ifthe supplier doesn’t acceptassignment. See page 8. If youwant to upgrade the frames, youpay any additional cost.

Medicare covered services of medical equipment and how much patient need to pay

Durable Medical Equipment covered items

What Medicare Covers

•Air fluidized beds •Blood glucose monitors •Bone growth (or osteogenesis) stimulators* •Canes (except white canes for the blind) •Commode chairs •Crutches •Home oxygen equipment and supplies* •Hospital beds •Infusion pumps and some medicines used in them •Lymphedema pumps/pneumatic compressiondevices* •Nebulizersand some medicines used in them (if reasonable and necessary) •Patient lifts* •Scooters •Suction pumps •Traction equipment •Transcutaneous electronic nerve stimulators (TENS)* •Ventilators or respiratory assist devices •Walkers •Wheelchairs(manual and power)

What You Pay
Generally, you pay 20% of theMedicare-approved amount afteryou pay your Medicare Part Bdeductiblefor the year ($135 in2009). Medicare pays the other80%. The Medicare-approvedamountis the lower of the actualcharge for the item or the feeMedicare sets for the item.However, the amount you paymay vary because Medicare paysfor different kinds of durablemedical equipment in differentways. You may be able to rent orbuy the equipment.

Note : You must get a Certificate of Medical Necessitybefore you can get this equipment.

Medicare coverage on Power wheelchairs and scooters

Power wheelchairs and scooters

For Medicare to cover a power wheelchair or scooter, your doctormust state that you need it because of your medical condition.Medicare won’t cover a power wheelchair or scooter that is onlyneeded and used outside of the home.

Most suppliers who work with Medicare are honest. There are afew who aren’t honest. Medicare is working with othergovernment agencies to protect you and the Medicare Programfrom dishonest suppliers of power wheelchairs and scooters.

For more information about Medicare’s coverage of powerwheelchairs or scooters, view the publication “ProtectingMedicare’s Power Wheelchair and Scooter Benefit.” Visitwww.medicare.gov and select “Find a Medicare Publication.” Youcan also call 1-800-MEDICARE(1-800-633-4227). TTY usersshould call 1-877-486-2048.

What is durable medical equipment? and does medicare cover

What is durable medical equipment?
Durable medical equipmentis reusable medical equipment such as walkers, wheelchairs, or hospital beds.

Does Medicare cover durable medical equipment?
Anyone who has Medicare Part B can get durable medicalequipment as long as the equipment is medically necessary.

When does Original Medicare cover durable medical equipment?
If you have Part B, Original Medicarecovers durable medicalequipment when your doctor or treating practitioner (such as anurse practitioner, physician assistant, or clinical nurse specialist)prescribes it for you to use in your home. A hospital or nursinghome that is providing you with Medicare-covered care can’tqualify as your “home” in this situation. However, a long-termcare facility can qualify as your home. Note: If you are in a skilled nursing facility and the facilityprovides you with durable medical equipment, the facility isresponsible for this equipment.