[het8612]

Got a denial from Medicare stating we need to provide an arterial blood gas (ABG) study along with additional documentation proving medical neccessity. We requested all documentation from the physician that we possibly could and resubmitted to Medicare. We then received another denial. They are saying they need the ABG. The physician didn't do an ABG, they only did O2 saturation tests on room air. LCD's state that either test will work for qualifying a patient for O2... I don't get it!

We sent this to appeals and it came back again saying they will not pay without the ABG. We are in Jurisdiction C and have never had to go through this before. What are we to do now? Any suggestions? Or, should we just write off? The patient is unwilling to pay personally, but needs the O2 for their O2 sat lingered in the mid 80's without O2. Dx: COPD, CAD, and OSA.

Any help is much appreciated!

Christian

[leejgbt]

What proof of the o2 sat did you sent to Medicare? You are correct that both ABGs and o2 sats are allowed. An ABG will "trump" an o2 sat though. I am wondering if this is that Medicare is not considering your proof adequate. Was it a copy of the actual test? Also, when you said you appealed it are you talking about a redetermination?

[het8612]

We first sent it for redetermination with all supporting documentation (progress notes with O2 sat readings, Rx, and completed CMN), then sent it to appeals after the third denial.

That actually may be the reason they continue to deny, Lee, when you ask the proof of the sat test. It may be because the readings were only documented in the clinical notes. If this is the case then that is just absolutely ridiculous. I don't know why I'm surprised though.

One would think because the physician has ordered the O2 based on her professional observations, provided proper documentation of the clinical evaluation, has proven it is medically necessary, and has signed her name stating she is certifying the information on the CMN is truthful and understands she can be held liable and possibly criminaly charged if incorrect, Medicare would cover this for the patient. I mean the patient could die without O2 support. Makes me sick that it has come to this extreme nit pickyness (if that is a word) in order to fight fraud and the mismanagement of funds. I guess we will continue to provide the O2 free of charge because the doctor has given us all she can.

Sorry for my soapbox! I know most who read this can understand my frustrations.

[leejgbt]

This disturbs me greatly. The rules say progess notes of the physician are supposed to be allowed for oximetries. Not all oximeters have printer capability. I think you should bring this to the DAC representative in your region for Medicare clarification. I will be bringing this up at our Association Board meeting to see if other have experienced something similar. I will keep you posted.

[het8612]

Sounds great...and thank you for your help in this matter. It does disturb me as well. We bust our tails taking care of patients, hound the offices for documentation, deal with reimbursement cuts, and still get no love. I don't get it.

And right, if they say to go by what the LCD says then the contracted auditers should do the same. I will take this further. Thank you once again for your help and keep me updated with what you hear.

Sincerely,

Christian

[Sleeping410]

I notice OSA was one of the DX codes you were using. Is the desaturation documented in the Sleep Study?

[Regina]

I was just checking for the changes to the Oxygen LCD in DME MAC A(which were not there yet, BTW), and I came across this Appendix at the bottom-

The term blood gas study in this policy refers to either an arterial blood gas (ABG) test or an oximetry test. An ABG is the direct measurement of the partial pressure of oxygen (PO2) on a sample of arterial blood. The PO2 is reported as mm Hg. An oximetry test is the indirect measurement of arterial oxygen saturation using a sensor on the ear or finger. The saturation is reported as a percent.