Oxygen Therapy Ordering, Documentation and Testing Requirements

For more information regarding durable medical equipment, contact SSM Health at Home at 1-800-924-2273 or visit the National Government Services website.

What is needed

  • Evidence of an in-person visit with a treating physician 30 days prior to dispensing.
  • An initial dispensing order. In the state of Wisconsin, Oxygen is considered a drug. An example of a Detailed Written Order (DWO) for oxygen is: 02 (item to be dispensed) at 2LPM (concentration) continuously (frequency) via nasal cannula (route of administration).
  • Signed certificate of medical necessity (CMN)/detailed written order after delivery.
  • Evidence of qualifying test results done within 30 days prior to dispensing or within 2 days of discharge from a hospital.
  • Sufficient documentation in the patient’s medical record to substantiate the necessity for the items ordered, prescribed liter flow, hours of usage (i.e. continuous, with rest, with activity, etc.) and delivery mode (i.e. nasal cannula, non-rebreather, bleed in to a device, etc.). Documentation on prescriptions or letters of medical necessity is not considered part of the medical record.
  • Documentation of the patient being reevaluated by the treating physician within 60-90 days after delivery and/or annually.

Coverage and Testing Specifications

  • The patient has a severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy, Hypoxia alone does not qualify OR a qualifying blood gas/oximetry study that was performed by a provider who is qualified to bill Medicare for the test – i.e., a Part A provider, a laboratory, an Independent Diagnostic Testing Facility (IDTF), or a physician.
  • If the test was performed during an inpatient hospital stay the test must be performed no earlier than 2 days prior to the hospital discharge date.
  • If the test was not performed during an inpatient hospital stay, the reported test must be performed while the beneficiary is in a chronic stable state – i.e., not during a period of acute illness or an exacerbation of their underlying disease.
  • Alternative treatment measures have been tried or considered and deemed clinically ineffective.

For more information or to make a referral, please call 800-924-2273.