CERT contractor creates uncertainty for oxygen providers

Sunday, November 22, 2009

NASHVILLE, Tenn. - Providers and auditors are at odds over documentation requirements for oxygen claims in jurisdictions B and C.

The problem: Providers do not have adequate progress notes to support medical necessity, according to a CMS contractor. HME stakeholders, however, say the local coverage determination (LCD) doesn't require them.

According to the Comprehensive Error Rate Testing (CERT) contractor, there must be documentation in the beneficiary's medical record within the six months prior to the date of the claim.

That's not in line with the LCD, most recently updated in June, said Kelly Riley, director of The MED Group's National Respiratory Network. The LCD requires documentation of an appropriate qualifying test, proof of delivery and the certificate of medical necessity, she said.

"Now, they are saying that they want documentation from the physician that says, for example, this patient was evaluated for COPD and still requires oxygen and still uses it," she said. "To hold the supplier responsible for something that was not even articulated in the policy is unreasonable. And what are the chances of the doctor having notes that specific? I don't think we are going to see that."

Provider Scott Lloyd, president of Extrakare in Norcross, Ga., said he's been routinely asked for additional progress notes this year. In all but one claim he was able to obtain the notes.

"For that claim, we gave them the most recent notes and a brief statement from the beneficiary stating that was the last time he's been to the doctor," said Lloyd. "When we've got a patient that is beyond their Medicare recertification date, we do not routinely collect progress notes."

Historically, the certificate of medical necessity (CMN) has stood on its own in qualifying the patient for oxygen, said provider Mary Gargiulo, general manager of Islamorada, Fla.-based Coral Medical.

"There's always been a requirement that the initial testing results be available, but nothing else on a continuing basis," she said. "Like usual, they are going back to require something from last year that they hadn't told us they were going to require."

Stakeholders seek clarification on the issue.