Respiratory Referrals
Information Required for Respiratory Referrals:
- Apnea monitor – settings & qualifying diagnosis, apnea event documentation
- BiPAP – sleep study date & documentation, as well as settings
- CPAP – sleep study date & documentation, as well as settings
- Date of oxygen saturation level (must be taken within 48 hrs. of hospital/SNF discharge or within 30 days from MD office)
- Hours per day needed
- Liter flow
- Nebulizer/aerosol medications - qualifying diagnosis (Chronic Obstructive Pulmonary Disease)
- Oxygen
Example of Typical Oxygen Order:
Continuous oxygen at 2 liters per minute for oxygen saturation level of 87 percent at rest. Taken at MD office – date. Patient must be in stable state (no E.R. Tests).
Qualifying Diagnosis for Home Oxygen Therapy:
- Asthmatic bronchitis (severe asthma)
- Congestive Heart Failure (CHF)
- Chronic Obstructive Pulmonary Disease (COPD)
- Corpulmonale
- Pneumonia
- Pulmonary disease (any respiratory disease with a qualifying
oxygen saturation level) - Pulmonary fibrosis
- Respiratory failure
Documentation Requirements:
- Certificate of Medical Necessity (CMN)
- Physician order (verbal or written)
- Others as required by Medicaid & Third Party Payers
Medicare Coverage Requirements for Oxygen:
A) Saturation level of 88 percent or less or PO2 (ABG) of 55 or less. If the patient has an O2 saturation reading of 89 percent or a PO2 level of 56-59 on room air, Medicare will consider coverage for oxygen for 3 months provided the patient has dependent edema to Congestive Heart Failure, cor pulmonale or hematocrit less than 56 percent. However, the patient must be retested between 61 – 90 days from the order date & the results of the repeat test must fall at or below an O2 saturation of 88 percent or a PO2 of 55. If this is not the case, the patient must pay privately or qualify for an indigent program.
AND/OR
B) This test must have been performed either while the patient was in a chronic stable state (not during exertion, ex: pulmonary rehab, not walking) within 30 days of physician’s order for oxygen or within 2 days of hospital/SNF discharge.
AND/OR
C) To qualify for a portable system the patient must be mobile within the home and qualifying test must not be taken overnight.
Information Required When Patient Tested at Exercise:
- O2 saturation on room air
- O2 saturation on room air at exercise
- O2 saturation on O2 at exercise to show improvement
Portable O2 Requirements:
If patient is tested overnight while sleeping, Medicare/Medicaid will not cover a portable system. Prior approval request is needed from physician describing the activities or exercise routine that requires a portable system.
Individual state Medicaid plans differ on oxygen qualifications (for example Medicaid of Virginia qualifying oxygen saturation is 88 percent but in South Carolina it is 90 percent). Please contact your AHC representative for complete clarification.
Individual insurance and managed care payors may have many differing policies regarding coverage and authorizations for all of our services. At Advanced Home Care, we have representatives available to verify and confirm coverage for your patient needs.
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