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CMS DISREGARDS O2 REQUIREMENTS UNDER EXERTION

Wednesday, February 28, 2018 @ 02:02 PM  posted by jbuytaert

2/28/2018
From: MiraVista

In its recent Quarterly HCPCS Update, CMS instituted changes to oxygen pricing modifiers related to volume adjustment. These changes will impose further rate reductions and likely cause harm to patients and DME suppliers alike.

In a December 7, 1992 Interim Final Rule, CMS found that Section 1834 of the Social Security Act is silent regarding volume adjustments when the prescribed oxygen liter flow varies according to the circumstances of the patient. As a result, CMS added the following regulatory language regarding volume adjustments:

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​Although this guidance has been on the books for over two decades, the change in pricing modifiers, effective April 1, 2018, will shift the physician education burden to suppliers.

Here’s what you need to know about the change:

Providers currently use three pricing modifiers for oxygen volume adjustments, based on the highest liter flow prescribed (regardless of modality):

  • QE is appended when the liter flow is less than 1 LPM. Payment is made at 50% of the stationary allowable.
  • QF is appended when the liter flow is greater than 4 LPM for cases where portable and stationary oxygen are used. Payment is made at 150% of the stationary rate; portable oxygen cannot be separately billed.
  • QG is appended when the liter flow is greater than 4 LPM for cases where only stationary oxygen is used. Payment is made at 150% of the stationary rate.

The April 2018 HCPCS Update significantly alters the definitions for the three existing modifiers. Eligibility for the volume adjustment rate increase is now contingent on the prescribed liter flow at rest.

New Modifiers

CMS also created three new, but related, modifiers to communicate when resting daytime and nighttime liter flow requirements are different. When the rates differ, CMS expects suppliers to average these liter flows prior to assessing eligibility for the volume adjustment. The following three modifiers apply to this scenario:

  • QA is appended when the average of daytime (at rest) and nighttime use is less than 1 LPM.
  • QB is appended when the average of daytime (at rest) and nighttime use is greater than 4 LPM and both stationary and portable modalities are used.
  • QR is appended when the average of daytime (at rest) and nighttime use is greater than 4 LPM and only stationary oxygen is used.

The following table shows the correlation between the new and existing modifiers:

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CMN Considerations

By disregarding the highest liter flow prescribed for the patient, the rule change complicates CMN preparation. Current CMN instructions do not speak to liter flow in the context of modality (at rest, exertion or nighttime use). Questions 5 and 6 read as follows:

  • Question 5: Enter the highest oxygen flow rate ordered for this patient in liters per minute. If less than 1 LPM, enter an “X”.
  • Question 6: If greater than 4 LPM is prescribed, enter results of most recent test taken on 4 LPM. This may be an (a) arterial blood gas PO2 and/or (b) oxygen saturation test with patient in a chronic stable state. Enter date of test (c).

These two questions drive claim processing logic and eligibility for the volume adjustment. The MACs just released a Joint DME MAC Publication with revised Billing Instructions related to the Oxygen CMN Question 5. But the CMS-484 form cannot be officially changed without OMB approval, and that process can take years. In the interim, this oversight will shift the physician education burden to suppliers.

There is no doubt this instruction will materially impact reimbursement for existing patients requiring high liter flow for day-to-day living. By doing so, CMS will discontinue added compensation for the special equipment these vulnerable patients require to maintain even modest quality of life standards. Combined with price cuts derived from competitive bidding and the 2006 budget neutrality, or double-dip, offsets, these changes create an increasingly difficult delivery model for suppliers.

MiraVista has contacted CMS to advocate for continuance of prior policies. For more details, guidance and insight on this issue, please join us for the 2018 Look Ahead for DME Suppliers on Thursday, March 8 at 1:00 PM (EST).

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