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Physician Documentation Requirements


  • Detailed Written Order That Contains:
    • Patient's Name
    • Detailed Description of the Item(s) to Be Ordered
    • Frequency of Use (Continuous, HS, or During Exercise)
    • Route of Administration (NC, Mask, Trach, PAP, etc.)
    • Liters per Minute
    • Length of Need the Patient Will Require the Item(s)
    • Physician's Printed Name
    • Physician's NPI
    • Physician's Signature
    • Physician's Date of Signature
  • Face-to-face evaluation dated within 6 months of the detailed written order documenting:
    • Patient's has a severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy; and
    • Alternative treatment measures have been tried or considered and deemed clinically ineffective; and
    • Pt has a qualifying ABG or pulse oximetry test:
      • Within 2 days of hospital discharge, or
      • Within 30 days of the written order as an Out Patient
        • Qualifying tests are one of the following:
        • At rest, on room air, in a chronic, stable state
        • During exercise, documenting all 3 of the following:
          • Saturation level at rest, on room air
          • Desaturation level, during exercise on room air
          • Saturation recovery level, after oxygen has been applied
      • During sleep*, the patient desaturation levels reach 88% or below for a cumulative total of at least 5 minutes during the study (not consecutive)

*Patients who have OSA and are tested during sleep for oxygen bled through a PAP device; the patient must be tested during titration:

  • The titration is conducted over a minimum of two (2) hours; and
  • During titration:
    • The AHI/RDI is reduced to less than or equal to an average of ten (10) events per hour; or
    • If the initial AHI/RDI was less than an average of ten (10) events per hour, the titration demonstrates further reduction in the AHI/RDI; and
  • Nocturnal oximetry conducted for the purpose for oxygen reimbursement qualification may only be performed after optimal PAP settings have been determined and the beneficiary is using the PAP device at those settings; and
  • The nocturnal oximetry conducted during the PSG demonstrates an oxygen saturation ≤ 88% for 5 minutes total (which need not be continuous)

M-F8:30 a.m.5:00 p.m.
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