Several months ago I wrote an article for this publication about the challenge some respiratory suppliers face in obtaining qualifying tests for oxygen patients in a timely fashion (“Building Bridges,” September 2003). As a possible solution, I focused on the DME Regional Carriers’ (DMERCs’) position on allowing respiratory suppliers to establish “test days” at their facilities. In a “test day” scenario, patients who need pulse oximetry testing to qualify for Medicare reimbursement for their oxygen can come to the oxygen supplier’s location where an independent laboratory performs the tests on-site. In addition, the laboratory provides sealed units for overnight pulse oximetry testing for patients unable to access the supplier’s location. The supplier may deliver and pick up the sealed overnight units for the patients, but the laboratory must handle all patient instruction in use of the testing devices and is responsible for downloading the test results and providing them to physicians.

The article generated numerous calls from suppliers, and some requested more information about establishing “test days” in their facilities. So does this process provide a viable solution to the timely testing issue?

No, the location of the testing is not the issue, says Tom Brown, president of Pulmonary Testing of Virginia, a Norfolk, Va-based provider of the pulse oximetry testing Medicare requires to qualify patients for oxygen reimbursement. “The primary issue remains reimbursement,” he says. “In 1993, a multiple pulse oximetry was reimbursed at a rate of $99.06. As of January 1, 2004, the reimbursement rate is $3.45 with no mileage reimbursement.”

It does not appear that the government will resolve the reimbursement issue in the near future. A provision in the US Senate’s version of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 included a co-pay for clinical laboratory services that would have required laboratories to find more than $18 billion in revenue over the next decade and made Medicare beneficiaries pay 20% of the cost of their laboratory tests. An intense grassroots effort by the Clinical Laboratory Management Association (CLMA) resulted in the removal of the co-pay provision from the final bill. However, there is still an attempt to obtain savings comparable to those of the co-pay provision ($18.6 billion), by cutting Medicare reimbursement for laboratory services combined with a 5- to 7-year freeze on the Consumer Price Index (CPI) inflation adjustments.¹

Of course, multiple pulse oximetry is not the only testing method accepted by Medicare for qualifying respiratory patients. As an alternative, laboratories often use a simple pulmonary stress test. Current reimbursement for this test averages about $105. It takes between 30 and 60 minutes to complete and, under Medicare guidelines, requires pre- and post-spirometry testing with a device that provides a printout of the test results. Additional guidelines require that these tests be performed under appropriate physician supervision.

An arterial blood gas study (ABG) is also an acceptable method of testing and carries a reimbursement average of $90. However, in addition to the invasiveness of the test procedure itself, it is not a test a physician would routinely offer in the office environment. According to Brown, the equipment required to process the bloodwork (which includes blood gas and co-oximetry) may cost as much as $50,000 and, if the blood is suspended in dry heparin, the test must be processed within 30 minutes.

What entity is actually qualified under Medicare guidelines to perform the test was another issue in our puzzle. In an April 2003 Q&A from a Respiratory Webinar, Region B stated that an oximetry test or ABG used to qualify a patient for oxygen may be performed by any Medicare provider who bills and is reimbursed under Medicare for the test. A DME provider does not meet that requirement, and this clarification also eliminates those testing laboratories that offer pulmonary testing without billing the Medicare program. In addition, according to Brown, many testing providers anticipate that a new Local Medical Review Policy (LMRP) may soon also prohibit home health nurses from performing testing to qualify patients for home oxygen therapy.

The key to getting around the testing roadblock in qualifying patients for the oxygen therapy they require may be flexibility. “Although there are different acceptable testing methods available to qualify the respiratory patient, the most effective test method varies according to the type of patient to be tested, the diligence of the laboratory, and the volume of patients to be tested,” says Mike Montgomery, president of Pulmocair of Northern California, a home health care provider based in Vacaville, Calif. “Just having access to a laboratory is not enough. We have to have ways to obtain laboratory testing quickly and within the established guidelines. If all patients were set up immediately after hospital discharge and had undergone qualifying testing prior to discharge, this would be a nonissue. But that is not the demographic that the respiratory industry routinely services. We have an eclectic mix of patients who require testing to qualify under the reimbursement guidelines established for home respiratory care.”

The laboratory Pulmocair uses seems to manage testing a large number of patients by combining scheduled home visits, multiple appointments in a manageable geographic location, and mailing sealed units to patients unable to access facilities, Montgomery says. Therefore, Montgomery has not needed to establish on-site testing at his location, which does come with certain downsides. “[On-site testing] is exceedingly disruptive to the workplace due to logistics and time requirements,” he says. “Some companies may be fortunate enough to have all or multiple options available to them, yet some companies find themselves with a limited few.”

Fortunately for patients, part of this plight is based on the home health care industry’s strong sense of patient advocacy. I have been in this industry many years, and I have never met a respiratory supplier who would consider refusing to service a patient whose need for home respiratory therapy has been established by a physician but who has not yet been tested. Oxygen therapy providers recognize the financial impact this has on their companies, yet they continue to manage their businesses based on their patients’ health care needs.

“All legal methods to obtain laboratory results must be used to help reduce the patient backlog,” Montgomery says. “The key is having all parties involved work together quickly to obtain the results and allow the patient to be serviced.”

Helen M. Farrell is a reimbursement consultant and CEO of MARS (Medical Accounting & Reimbursement Services) in Chesapeake, Va. Contact her at (757) 410-1732.

Reference
1. Ayres K. Washington Report. MLO (Medical Laboratory Observer). 2003; 35(12).