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December 2016 Texas Medicaid Provider Procedures Manual

Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook : 2 Texas Medicaid (Title XIX) Home Health Services : 2.2 Services, Benefits, Limitations and Prior Authorization : 2.2.19 Respiratory Equipment and Supplies : 2.2.19.11 Oxygen Therapy

2.2.19.11
Oxygen therapy home delivery systems may be reimbursed for rental only once per month.
Moisture exchangers for use with non-mechanically ventilated clients may be considered for reimbursement when billed with procedure code A9900.
Rental of oxygen equipment includes all supplies and refills.
One of the following clinical indications must be present when requesting approval for in-home oxygen therapy:
Hypoxemia-related symptoms and findings that might be expected to improve with oxygen therapy (examples of these symptoms and findings are pulmonary hypertension, recurring congestive heart failure due to chronic cor pulmonale, erythrocytosis, impairment of the cognitive process, nocturnal restlessness, and morning headache).
Severe lung disease, such as COPD, diffuse interstitial lung disease, whether known or unknown etiology such as cystic fibrosis, bronchiectasis or widespread pulmonary neoplasm.
2.2.19.11.1
Providers must use procedure code E1390 when billing for the rental of an oxygen concentrator system. The reimbursement payment for the rental of the oxygen concentrator system includes, but is not limited to, cannula or mask, tubing, and humidification. These items will not be reimbursed separately.
If other types of oxygen therapy home delivery systems are required, documentation of medical necessity exception must be provided.
Other types of delivery systems include:
Note:
The reimbursement for compressed gas cylinder and liquid oxygen reservoir systems includes all of the supplies that are noted in the procedure code description.
Portable oxygen systems—Portable oxygen therapy may be prior authorized if the medical necessity conditions are met and the medical documentation indicates that the client requires the use of oxygen in the home and would benefit from the use of a portable oxygen system when traveling outside the home environment.
Portable oxygen systems are not considered a benefit of the Home Health Services Program for clients who qualify for oxygen solely based on blood gas studies obtained during sleep.
Providers must use procedure codes E0431, E0434, and K0738 when billing for the portable oxygen systems. When procedure code K0738 is billed for the same dates of service as procedure code E0431, procedure code E0431 will be denied.
Rental of the portable oxygen system includes all supplies and refills. Refills for a client-owned system must be obtained from a DSHS-licensed vendor.
2.2.19.11.2
All oxygen therapy, supplies, and related equipment requires prior authorization. Humidifiers may not be prior authorized separately for rental for use with oxygen equipment. Multiple oxygen delivery systems (e.g., liquid or gas) will not be prior authorized concurrently. Supplies and refills may be prior authorized for those clients who own their own oxygen systems.
Note:
In addition to the completed Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form, a Medicaid Certificate of Medical Necessity for CPAP/BiPAP or Oxygen Therapy form must be completed, signed, and dated by the physician familiar with the client and submitted by the provider.
2.2.19.11.3
Prior authorization of home oxygen therapy for the initial period of three months will be granted if the Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form and the Medicaid Certificate of Medical Necessity for CPAP or BiPAP or Oxygen Therapy form is completed and all of the following conditions are met:
For clients who are 20 years of age and younger, one of the following parameters must be used:
An arterial PO2 at or below 56 mm Hg or an arterial oxygen saturation at or below 89 percent, taken at rest, breathing room air, or during sleep and associated with signs or symptoms reasonably attributed to hypoxemia.
Hypoxemia associated with obstructive sleep apnea must be unresponsive to CPAP or BiPAP S therapy before oxygen therapy can be approved. In these cases, coverage is provided only for use of oxygen during sleep, and then only one type of delivery system will be considered a benefit under the Home Health Services Program.
Portable oxygen systems are considered a benefit of the Home Health Services Program when the medical documentation indicates that the client requires the use of oxygen in the home and would benefit from the use of a portable oxygen system when traveling outside the home environment. Portable oxygen systems are not considered a benefit of the Home Health Services Program when traveling outside the home environment for clients who qualify for oxygen usage based solely on oxygen saturation levels during sleep.
A client who demonstrates an arterial PO2 at or above 56 mm Hg, or an arterial oxygen saturation at or above 89 percent, during the day while at rest and who subsequently experiences a decreased arterial PO2 of 55 mm Hg or below, or decreased arterial oxygen saturation of 88 percent or below during exercise. In this case supplemental oxygen can be provided if there is evidence that the use of oxygen improves the hypoxemia that was demonstrated during exercise when the client was breathing room air.
In-home oxygen therapy can be approved for cluster headaches with the documentation of both the following clinical indications:
Note:
2.2.19.11.4
Prior authorization of oxygen therapy after an initial three-month rental period may be granted with the submission of a new completed Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form and a new Medicaid Certificate of Medical Necessity for CPAP/BiPAP or Oxygen Therapy form and the following:
Note:

Texas Medicaid & Healthcare Partnership
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