Indicate the patient’s name, permanent legal address, telephone number and his/her Medicare ID as it appears on his/her Medicare card and on the claim form.
Eligibility for coverage of home oxygen therapy under Medicare requires the ordering physician or allowed Non-Physician Practitioner (NPP)1 to complete a Certificate of Medical Necessity (CMN), OBM Form CMS-484, to establish that coverage criteria are met.
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.
If authorization is to be based on an oxygen saturation study, please attach summary of protocol used and the oximetry graph(s).
QUALIFYING blood gas or oxygen saturation result: A. Testing must be performed while the patient is in a chronic stable state: - As an outpatient, from a qualified testing provider or hospice: within 30 days prior to initial certification, or - As an inpatient transitioning home: within two (2) days prior to discharge.
When oxygen is covered based on an oxygen study obtained during exercise, there must be documentation of three (3) oxygen studies in the patient’s medical record- i.e., testing at rest without oxygen, testing during exercise without oxygen, and testing during exercise with oxygen applied ( to demonstrate the improvement of the
Use this form to record and document oximetry at rest and/ or ambulation or when ABG is not possible/ practical. Out patient Labs and Pulmonary Function Labs must perform long-term study including change in distance walked.
Maintain oxygen saturation levels at or above ________ % (if left blank, default percentage will be 90%), while on an oxygen conserving setting range of 1 - 5. If patient qualifies for the oxygen conserving device, please check off one of the following systems: Standard OCD …
MEDICARE OXYGEN TESTING ORDER FORM Patient Name: HIC# Current Oxygen Order: Option I ____“Spot-check Oximetry; patient on room air: Usually obtained in physician’s office or hospital, (DME provider cannot perform) If 02 saturation 88% or below at rest, both stationary and portable oxygen covered; no further testing required. Option II
Testing – Testing must be completed within 48 hours of a hospital discharge, or within 30 days of an outpatient office visit. Outpatient testing must be conducted while the patient is in their chronic, stable state.