[Regina]

I have a patient whose O2 sat was 89%. We got another CMN after three months as required. The O2 sat was still 89%. The length of need on that CMN is 99. According to a Medicare CSR, if the length of need is 99, we shouldn't need a recert CMN at the one year mark. Our claims are denying though. Anyone have experience with this?

[leejgbt]

Recertification CMN is Required:

1. 12 months after Initial Certification (i.e., with the thirteenth month's claim) for Group I.
2. 3 months after Initial Certification (i.e., with the fourth month's claim) for Group II.

Testing and Visit Requirements:



Recertification following initial certification situations 1 and 2

• For patients initially meeting Group I criteria, the most recent qualifying blood gas study prior to the thirteenth month of therapy must be reported on the Recertification CMN.
• For patients initially meeting Group II criteria, the most recent blood gas study that was performed between the 61st and 90th day following Initial Certification must be reported on the Recertification CMN. If a qualifying test is not obtained between the 61st and 90th day of home oxygen therapy but the patient continues to use oxygen and a test is obtained at a later date, if that test meets Group I or II criteria, coverage would resume beginning with the date of that test.
• For patients initially meeting group I or II criteria, the patient must be seen and re-evaluated by the treating physician within 90 days prior to the date of any Recertification. If the physician visit is not obtained within the 90-day window but the patient continues to use oxygen and the visit is obtained at a later date, coverage would resume beginning with the date of that visit.

This is the LCD. It says a Recertification CMN is necessary for the fourth month's claim. However, you will notice that it does not mention whether a Recertification, if Group II, is necessary at the 12th month as it does for Group I. But, a Recertification IS ALWAYS due at the 12th month no matter whether it is Group I or II. It addresses this by saying NOTHING changes the Recertification schedule.

So, for a patient meeting Group II criteria you have to do an Initial CMN, a "first" Recerification CMN for month 4 and a Recertification CMN for month 13.

[Regina]

I agree that it doesn't say recertification is due at the 12th month, but it would be nice if the people who work at Medicare knew the rules!
Thanks for your input! You have been very helpful.