Medicare Documentation Requirements for Home Oxygen Therapy

Overview

Medicare covers home oxygen therapy when patients meet specific testing requirements and the medical record demonstrates both the medical necessity and that oxygen will improve the patient’s condition in the home setting.

Testing Requirements

Patients must qualify through one of the following groups:

Group I Coverage (Most Common)

Requires a diagnosis that causes hypoxemia AND one of the following qualifying tests:

A. When Tested at Rest While Awake:

B. During Sleep (for patients with normal daytime oxygen levels):

C. During Exercise (if oxygen saturation/ABG normal at rest):

Common qualifying diagnoses include but are not limited to:

COPD
Interstitial lung disease
Pulmonary fibrosis
Bronchiectasis
Cystic fibrosis
Primary pulmonary hypertension
Advanced heart failure

Group II Coverage

Oxygen saturation of 89% OR ABG PO2 56-59 mmHg AND one of:

Group III Coverage

For patients who don’t meet Group I or II criteria but have a condition documented in medical literature to improve with oxygen (e.g., cluster headaches)

Required Testing Documentation

Testing at Rest

Single qualifying blood gas study performed while awake and at rest
Must be done by treating practitioner or qualified laboratory/facility
Can be either arterial blood gas or pulse oximetry
Must be performed in-person (remote testing not accepted)
Must be performed in-person (remote testing not accepted)

Testing During Exercise

Three tests required in same testing session:

Testing During Sleep

Home testing must be:

Special Requirements for Sleep Apnea Patients

Equipment Coverage Rules

Stationary Concentrators

Portable Systems (Gas Tanks or Concentrators)

Only covered if patient qualifies through testing at rest or exercise
Not covered if patient only qualifies through sleep testing
Must be mobile within home to qualify for portable system
Supplier must provide adequate contents/batteries for patient's needs

Documentation Tips

1. Medical record must clearly document:

2. Treating practitioner notes can be supplemented with:

3. Don’t include clinical information on the oxygen order/prescription – keep this in the medical record

4. Minor documentation deficiencies can be addressed through a dated addendum to the medical record

Additional Notes

Prescriber must see patient within 30 days prior to ordering home oxygen
For Group II patients, retesting is required between 61-90 days after starting oxygen
Medical necessity must be ongoing for coverage to continue
Suppliers cannot perform qualifying oxygen tests

We provide detailed guides with sample documentation language for specific conditions – contact us for these resources.

Need help qualifying a patient? Contact our clinical team to review documentation requirements for your specific situation.