Oxygen LCD needs some ‘finer points’

• Stakeholders have been eagerly awaiting the LCD and policy article, following a proposed national coverage determination for oxygen published in July 2021 and a final NCD in September 2021. 
• As with any change this significant, the devil is in the details, and stakeholders are calling some parts of the LCD and policy article “muddied.” 
• At the end of the day, stakeholders say providers need clear documentation from physicians and treating practitioners. 

WASHINGTON – The new local coverage determination for oxygen is more or less what industry stakeholders expected, but they do have questions about patient groupings and new modifiers. 

The LCD lacks some specifics that concern Andrea Stark, a reimbursement consultant with MiraVista. For example, the groups under which patients can qualify for oxygen are “muddied,” and cluster headaches, which is what “blew this whole thing wide open,” are barely mentioned.   

“There’s no language regarding unique treatment protocols for cluster headache patients,” she said. “They are basically lobbed into a new group 3, which is a broad (category) and the nuances of Group 3 and Group 4 is muddied.”  

The LCD and policy article, which were published Nov. 18 and which go into effect Jan. 1, remove references to chronic stable state, severe lung disease and the CMN requirement. 

Even though revaluation and retesting are no longer required for group 1 patients, there’s still an obligation to ensure equipment remains reasonable and necessary, yet there’s no mention of the words acute or chronic in the LCD or policy article, Stark also points out. 

“But the terms are featured profusely throughout the NCD guidance,” she said. “How are suppliers supposed to tackle the acute need patients without incurring liability?”   

Stakeholders also have questions about modifiers. A request to add three new oxygen modifiers – N1, N2 and N3 – to the LCD was on the agenda for a CMS HCPCS Public Meeting, but they're not mentioned in the LCD or policy article, says Kim Brummett, senior vice president of regulatory affairs for AAHomecare.   

“If the N modifiers come about, is the KX modifier going away,” she said. “And, if they wanted to create new modifiers, it would have been nice if the LCD and article came out with the modifiers. In January, they are going to come out with these new oxygen modifiers and we’re going to have to regroup and re-educate. This needs some finer points.”  

For now, the best thing DME providers can do is educate themselves and their staff on the LCD, says Ronda Buhrmester, senior director of payer relations and reimbursement for VGM & Associates. 

“There’s good things coming in the LCD, as we predicted for patients and suppliers,” she said. “There is some concern in the future with audits and scrutiny in the medical records, but that’s the same with any DME product. As long as the physicians and treating practitioners document clearly why (oxygen) is needed and continues to be needed, there shouldn’t be any question.”  

• Read what Andrea Stark had to say about the end of the CMN requirement, a significant change in the new oxygen NCD. 
• Read why the Council for Quality Respiratory Care believes an oxygen template is needed under the new oxygen NCD.