CERTIFICATE
OF MEDICAL NECESSITY QUESTIONS
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NOTE: Questions in
this section should be answered accurately
to reflect the true condition of the
patient. Your answers to specific
questions are used by Medicare to
establish whether specific items are
reimbursable.
Question 1: Coverage
for home oxygen cannot be authorized
until the attending physician certifies
to the extent of hypoxemia and the
need for oxygen as evidenced by the
results of recent ABGs and /or oxygen
saturation tests on the patient. Test
results must be entered on the CMN.
Initial claims must contain the results
of an arterial blood gas test and/or
saturation test. Blood gas study results
define the likelihood of coverage
into three (3) groups:
- If PaO2 is less or equal to
55 mm Hg or SaO2 is less than
88% - covered
- If PaO2=56-59 mm Hg or SaO2=89%
- covered if: dependent edema
suggesting congestive heart failure,
"P" pulmonale on EKG (P wave greater
than 3 mm , or erthrocythemia,
with hematocrit, is greater than
56%.)
NOTE: The patient
falling within this range will
require recertificaton, involving
retesting, 61 to 90 days after
the start of therapy. If the patient
is retested and still falls within
the marginal range, there is no
need for another test to qualify
for Medicare reimbursement.
- If PaO2 is equal to or greater
than 60 mm Hg or SaO2 is equal
to or greater than 90% - coverage
unlikely.
Question 2: The purpose
of this question is to make sure that
the reported test result documents
the necessity for chronic oxygen use
in the home setting. The qualifying
test must reflect the patient's chronic
cardiopulmonary state. The test which
is submitted must not be one obtained
during an acute cardiopulmonary exacerbation
- e.g., during an emergency room visit.
Question 3: The condition
of test completed at Rest, Exercise
or Sleep.
Question 4: Name/Address
of Physician/Facility Performing Test
Question 5: If patient
meets Medicare coverage guidelines,
and is mobile in home, "Y" should
be circled if portable oxygen is ordered.
Question 6: Enter
highest oxygen flow rate "LPM". (PRN
is not acceptable.)
Question 7: If flow
rate not greater than 4 LPM, Not Applicable.
If over 4 LPM, enter most recent test
results, and date of test.
Question 8, 9, 10:
Answer only if PO2=56-59 or Oxygen
SAT=89%
Information courtesy of Health-E-Quip
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