It’s good news when you get a new oxygen patient. It’s bad news when there is no local means of testing to qualify the patient. Sound familiar?

How about this scenario: You receive a telephone call from your local family practice physician’s office with a prescription for nocturnal oxygen. The physician has not qualified this Medicare patient and cannot complete the certificate of medical necessity (CMN). What can be done? The qualifying overnight oximetry test must be performed to verify medical necessity to complete the CMN, thus meeting Medicare criteria to receive reimbursement for oxygen services.

Just the Facts
Just how do you evaluate the oximetry programs available today for cost-effectiveness and regulatory prowess? Start with a historical perspective. In 1985, Medicare established oxygen payment based on coverage criteria that encompass patients’ specific oxygenation levels. With the intent to prevent fraud and abuse, HME providers were prohibited from testing their own oxygen patients.

Independent diagnostic testing facilities (IDTFs) emerged with patients going to the testing facilities or qualified personnel going to the patient’s residence. Over time and with CPT fee schedule reductions, the majority of pulmonary-related IDTFs were forced out of business.

Is seamless access to arterial blood gas and/or oximetry testing for all potential oxygen patients a reality in 2005? You would certainly hope so.

Today’s qualification process can be broken into seven parts:

1. Patient has appointment with physician.
2. Physician writes prescription for oximetry to see if the patient needs and qualifies for oxygen.
3. IDTF, outpatient/hospital facilities, or physician’s office performs testing.
        3A. (IDTF option) Patient performs test via encrypted system and results
                go to IDTF and on to the physicia
        3B. Patient qualifies.
4. Oxygen is ordered and set up on the patient by HME provider.
5. The blank CMN is sent to the physician to be filled out.
6. The CMN is received by the HME provider and reviewed for accuracy.
7. If the CMN is accurate, the oxygen is billed. If the CMN is found to lack qualifying information, the CMN is returned to the physician for completion.

Jacquelyn M. McClure, RRT Thomas J. Williams, MBA, RRT

So what’s the problem? Access to testing is the problem. Physician offices do not have oximeters or are not set up for nocturnal testing. Do they depend on IDTFs to provide the equipment and perform the testing? Local IDTFs went by the wayside after the last lowering of the physician fee schedules for overnight oximetry testing. Getting a patient to an outpatient facility or to the hospital for testing can be difficult. It is estimated that 80% of new oxygen referrals are written by primary care physicians and come from their offices.

So let’s review; the physician offices do not own oximeters and most markets may have only one local IDTF—but most have none. There is minimal to no payment for the testing, no sense of urgency to get the testing done, medical necessity for oxygen cannot be established, and patients are unable to receive oxygen therapy. Are we getting the picture?

There is more. Technically, the HME provider is not supposed to perform the oximetry test if the test is to qualify a Medicare patient, and only now, based on guideline changes, can they own the oximeters and deliver them to patients on behalf of the IDTF. However, it is the IDTF that conducts and bills for the studies.

Four companies are currently offering Web-based oxygen qualification. IDTF options became more popular after the current clarification about HME’s involvement with overnight oximetry testing. The current Medicare policy reads that beneficiaries may self-administer home-based overnight oximetry tests under the direction of a Medicare-enrolled IDTF. An HME provider or other entity may deliver a pulse oximeter and transmit the test results to the IDTF if:

• the beneficiary’s physician has ordered the test;
• the test is performed under the direction of a Medicare-approved IDTF;
• the IDTF provides written instructions and includes access to address other concerns/questions;
• the test unit is sealed and tamper-proof so results cannot be manipulated and are visible only to the IDTF that sends them to the beneficiary’s physician; and
• CMS does not intend to regulate ownership of the testing unit or technology used to transmit the results.

Three of the current companies are their own IDTFs and the other sends the encrypted results to an independent IDTF. Three of the companies have exclusive rights to a particular brand while the remaining one offers choice.

Using one of these systems can: assist you in facilitating the qualifying of your oxygen patients; enable faster billing with one of the IDTFs if the patient’s Medicare eligibility is verified before testing; eliminate the need for in-office testing of oxygen patients or secondary independent laboratory, depending on medical necessity; generate an appropriate charge; and foster better rapport with physicians by facilitating comprehensive results.

Costs and Economics
The costs of qualifying Medicare patients for home oxygen can add up quickly. This is why the four main IDTFs are all useful when primary care physicians do not have office testing capabilities. IDTFs can also be great tools for diagnostic evaluation of patients who need oxygen at night—and don’t forget the great market potential when it is difficult to find IDTFs for initial testing or retesting.

So what do you do? Understand the technology and service providers because they are different. Get a written response from your health care attorney. Be involved with your state and national associations and remember, the risk is on you. DP

Jacquelyn M. McClure, RRT, directs the national respiratory network and orchestrates government relations for The MED Group, Lubbock, Tex. Thomas J. Williams, MBA, RRT, is managing director of Strategic Dynamics, Scottsdale, Ariz. Williams can be reached through his Web site: www.strategicdynamicsfirm.com.