42 C.F.R. § 414.226 Oxygen and oxygen equipment.
Title 42 - Public Health
(a) Payment rules. (1) Payment for rental of oxygen equipment and purchase of oxygen contents is made based on a monthly fee schedule amount. (2) Monthly fee schedule payments continue until medical necessity ends. (b) Monthly fee schedule amount. (1) Monthly fee schedule amounts are separately calculated for the following items: (i) Stationary oxygen equipment and oxygen contents (stationary and portable oxygen contents). (ii) Portable oxygen equipment only. (iii) Stationary and portable oxygen contents only. (iv) Portable oxygen contents only. (2) For 1989 and 1990, the monthly fee schedule amounts are the local payment amounts determined as follows: (i) The carrier determines the base local average monthly payment rate equal to the total reasonable charges for the item for the 12-month period ending December 1986 divided by the total number of months for all beneficiaries receiving the item for the same period. In determining the local average monthly payment rate, the following limitations apply: (A) Purchase charges for oxygen systems are not included as items classified under paragraph (b)(1)(i) of this section. (B) Purchase charges for portable equipment are not included as items classified under paragraph (b)(1)(ii) of this section. (ii) The carrier determines the local monthly payment amount equal to 0.95 times the base local average monthly payment amount adjusted by the change in the CPI-U for the six-month period ending December 1987. (3) For years after 1990, the fee schedule amounts are determined using the methodology contained in §414.220 (d), (e), and (f). (c) Application of monthly fee schedule amounts. (1) The fee schedule amount for items described in paragraph (b)(1)(i) of this section is paid when the beneficiary rents a stationary oxygen system. (2) Subject to the limitation set forth in paragraph (d)(2) of this section, the fee schedule amount for items described in paragraph (b)(1)(ii) of this section is paid when the beneficiary rents a portable oxygen system. (3) The fee schedule amount for items described in paragraph (b)(1)(iii) of this section is paid when the beneficiary owns a stationary gaseous or liquid oxygen system. (4) The fee schedule amount for items described in paragraph (b)(1)(iv) of this section is paid when the beneficiary owns or rents a portable gaseous or portable liquid oxygen system and uses either a stationary oxygen concentrator or no stationary oxygen system. (d) Volume adjustments: (1) The fee schedule amount for an item described in paragraph (b)(1)(i) of this section is adjusted as follows: (i) If the attending physician prescribes an oxygen flow rate exceeding four liters per minute, the fee schedule amount is increased by 50 percent, subject to the limit in paragraph (d)(2) of this section. (ii) If the attending physician prescribes an oxygen flow rate of less than one liter per minute, the fee schedule amount is decreased by 50 percent. (2) If portable oxygen equipment is used and the prescribed oxygen flow rate exceeds four liters per minute, the total fee schedule amount recognized for payment is limited to the higher of— (i) The sum of the monthly fee schedule amount for the items described in paragraphs (b)(1)(i) and (ii) of this section; or (ii) The adjusted fee schedule amount described in paragraph (d)(1)(i) of this section. (3) In establishing the volume adjustment for those beneficiaries whose physicians prescribe varying flow rates, the following rules apply: (i) If the prescribed flow rate is different for stationary oxygen equipment than for portable oxygen equipment, the flow rate for the stationary equipment is used. (ii) 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. (iii) If the prescribed flow rate is different for nighttime use and daytime use, the average of the two flow rates is used. [57 FR 57690, Dec. 7, 1992]
Title 42: Public Health
PART 414—PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES
Subpart D—Payment for Durable Medical Equipment and Prosthetic and Orthotic Devices
§ 414.226 Oxygen and oxygen equipment.
