Medicare’s Provision of Coverage for Equipment and Oxygen

Let’s first review Medicare payment for oxygen and oxygen equipment before talking about oxygen flow rate modifications. Medicare reimburses each beneficiary according to a monthly charge schedule for oxygen and oxygen-related equipment. This monthly charge schedule amount for stationary oxygen equipment includes the oxygen apparatus, contents, and supplies; it is subject to change based on the prescription oxygen dosage (liters per minute, or LPM) and whether portable oxygen is also prescribed. The following payment guidelines, which relate to modifications to the monthly payment amounts for oxygen and oxygen equipment depending on the patient’s prescribed oxygen flow rate, are included in Section 30.6.1 of Chapter 20 of the Medicare Claims Processing Manual:

The charge schedule amount for stationary oxygen rental is lowered by 50% if the recommended oxygen flow rate is less than 1 LPM.
Under the following circumstances, the fee schedule amount for stationary oxygen equipment is raised.

When both circumstances hold true, MACs employ the more advanced of the two available add-ons. Perhaps your MAC won’t cover both add-ons:

Volume Adjustment: The charge schedule amount for stationary oxygen rental is raised by 50% if the required amount of oxygen for stationary equipment surpasses 4 LPM. MACs employ the recommended amount for stationary systems and for patients at rest if the prescribed liter flow for stationary oxygen is different from that for portable oxygen or from that for rest and exercise. When determining the recommended liter flow for daytime and nighttime use, MACs take the average of the two rates.

Portable Add-on: The fee schedule amount for portable equipment is added to the fee schedule amount for stationary oxygen rental if portable oxygen is prescribed.

Medicare Modifiers for Oxygen Flow Rate

The following three new pricing modifiers are added to the HCPCS file with effect from April 1, 2018, to help with identifying the prescribed flow rate on the claim form and to ensure the appropriate use of modifiers in all cases based on the prescribed flow rate at rest (or at night, or based on the average of the rate at rest and at night, if applicable), in accordance with Federal regulations:

QA : Requirements for stationary oxygen during the day vary from those for nocturnal use, and the average of these two levels is less than one liter per minute (LPM).

QB : The recommended dosages of stationary oxygen are different for use during the day and at night, and the sum of the two doses is greater than 4 liters per minute (LPM). Portable oxygen is also recommended.

QR : Different volumes of stationary oxygen are prescribed for usage during the day and at night, with the average being more than 4 liters per minute (LPM).

 Additionally, the existing QE, QF, and QG modifiers are revised to clarify that the prescribed flow rate at rest is used in accordance with regulations at 42 CFR 414.226(e)(3). This section instructs that if the prescribed flow rate is different for the patient at rest than for the patient at exercise, the flow rate for the patient at rest is used. Effective April 1, 2018, these modifiers are revised to read:

 The prescribed amount of stationary oxygen while at rest is less than 1 liter per minute (LPM)

QE : Less than one liter per minute (LPM) of stationary oxygen is the recommended dosage when at rest.

QF : When stationary oxygen consumption during rest surpasses 4 liters per minute (LPM), portable oxygen is advised.

QG : More than 4 liters per minute (LPM) of stationary oxygen is required when at rest.

Prior to payment, any claims involving oxygen flow rates greater than four liters per minute must be reviewed by a member of the MAC medical staff, under the Medicare National Coverage Determinations Manual, Part 4, Chapter 1.

Suppliers use the modifier “QE” if the recommended oxygen concentration is less than 1 LPM, while Home Health Agencies (HHAs) use revenue code 0602. There is a fifty percent reduction in the monthly payment amount for stationary oxygen.
Suppliers use the modifier “QG” if the recommended oxygen flow rate is more than 4 LPM, while HHAs use revenue code 0603. There is a fifty percent increase in the monthly payment amount for stationary oxygen.
In cases where the recommended oxygen dosage surpasses 4LPM and portable oxygen is required, providers utilize the modifier “QF,” whereas HHAs utilize revenue code 0604. Either 50% of the monthly stationary oxygen payment amount or the fee schedule amount for the portable oxygen add-on is added to the monthly stationary oxygen payment.

Oxygen Charge Schedule: Totals

Claims for monthly oxygen volume adjustments must indicate the appropriate HCPCS modifier described below as applicable. Oxygen fee schedule amounts are adjusted as follows:

• If the prescribed amount of oxygen is less than 1 LPM, suppliers use either of the following modifiers with the stationary oxygen HCPCS code:
• The modifier “QE”; HHAs use revenue code 0602. The monthly payment amount for stationary oxygen is reduced by 50 percent.
• The modifier “QA”; the monthly payment amount for stationary oxygen is reduced by 50 percent. This modifier is used when the prescribed flow rate is different for nighttime use and daytime use and the average of the two flow rates is used in determining the volume adjustment.
• If the prescribed amount of oxygen is greater than 4 LPM, suppliers use either of the following modifiers with the stationary oxygen HCPCS code:
  • The modifier “QG”; HHAs use revenue code 0603. The monthly payment amount for stationary oxygen is increased by 50 percent.
  • The modifier “QR”; HHAs use revenue code 0603. The monthly payment amount for stationary oxygen is increased by 50 percent.
• If the prescribed amount of oxygen is greater than 4 LPM and portable oxygen is prescribed, suppliers use either of the following modifiers with both the stationary and portable oxygen HCPCS code:
• The modifier “QF”; HHAs use revenue code 0604. If the prescribed flow rate differs between stationary and portable oxygen equipment, the flow rate for the stationary equipment is used. The monthly payment for stationary oxygen is increased by the higher of 50 percent of the monthly stationary oxygen payment amount or the fee schedule amount for the portable oxygen add-on. Separate monthly payment is not allowed for the portable equipment if the stationary oxygen fee schedule amount is increased by 50 percent. Effective April 1, 2017, the modifier “QF” must be used with both the stationary and portable oxygen equipment codes.
• The modifier “QB”; HHAs use revenue code 0604. If the prescribed flow rate differs between stationary and portable oxygen equipment, the flow rate for the stationary equipment is used. The monthly payment for stationary oxygen is increased by the higher of 50 percent of the monthly stationary payment amount or the fee schedule amount for the portable oxygen add-on. Separate monthly payment is not allowed for the portable equipment if the stationary oxygen fee schedule amount is increased by 50 percent. Effective April 1, 2018, the modifier “QB” must be used with both the stationary and portable oxygen equipment codes. The stationary and portable oxygen equipment QB fee schedule amounts will be added to the DMEPOS fee schedule file effective April 1, 2018.
• The stationary oxygen QF and QB fee schedule amounts on the DMEPOS fee schedule file represent 100 percent of the stationary oxygen allowed fee schedule amount. The portable oxygen equipment add-on QF and QB fee schedule amount on the file by state represent the higher of:
  • 50 percent of the monthly stationary oxygen payment amount (codes E0424, E0439, E1390, or E1391); or
  • The fee schedule amount for the portable oxygen add-on (codes E0431, E0433, E0434, E1392, or K0738).