Home Oxygen Qualification & Prescription Note (Medicare)

Patient: [Full name], [DOB], [MRN]

Date: [Encounter date]

Treating Practitioner: [Name], [Credentials], NPI: [NPI]

Encounter Type: [in-person / telehealth]

Coverage Stage: [initial qualification / continued coverage (re-qualification) / equipment replacement]

Chief Concern

[Reason for evaluation related to home oxygen] (One concise line; e.g., evaluation for oxygen due to documented hypoxemia or reassessment for continued coverage.)

Clinical Summary

[Brief clinical synopsis] (Summarize underlying cardiopulmonary diagnosis, current symptom burden and functional impact, where hypoxemia occurs—rest, exertion, and/or sleep—and how it was demonstrated. Keep to 2–4 sentences.)

History of Present Illness

[Dyspnea symptoms] (Describe characteristics at rest vs exertion, triggers, relieving factors, frequency, severity, and impact on activities.)

[Functional limitations] (ADL impacts, baseline walking distance and need to stop/recover, use of assistive devices, ability to perform instrumental ADLs.)

[Course and context] (Onset acute vs chronic, stability vs worsening, recent exacerbation or hospitalization with dates if relevant, current and prior therapies for underlying condition—include adequacy and adherence, especially if hypoxemia is borderline.)

[Sleep-related breathing considerations] (If OSA present: document PAP therapy status, adherence, residual AHI, and adequacy of treatment. Omit if not applicable.)

[Smoking and home safety] (Briefly note current smoking status and any home safety considerations relevant to oxygen use.)

Relevant Medical History

• Diagnoses relevant to oxygen need: [Cardiopulmonary and related conditions] (e.g., COPD, ILD, CHF, pulmonary hypertension/cor pulmonale, obesity hypoventilation, neuromuscular disease)
  • Group II qualifying comorbidities: [Finding, supporting evidence, and date] (If considering Group II: explicitly document dependent edema/CHF, pulmonary hypertension/cor pulmonale, or erythrocytosis with dated supporting evidence. Omit if not applicable.)
• Current respiratory/cardiac therapies: [Inhalers/nebulizers], [Diuretics], [Pulmonary vasodilators], [PAP therapy if applicable], [Other relevant therapies]

Physical Examination

(If no exam performed, state "Exam not performed" with rationale if relevant.)

• Vitals: BP [value], HR [value], RR [value], SpO₂ [value]% on [room air / oxygen at X L/min]
• General: [Appearance], [Level of respiratory distress]
• Lungs: [Breath sounds], [Work of breathing], [Accessory muscle use]
• Cardiac: [Rhythm], [Murmurs], [JVP if assessed]
• Extremities: Dependent edema: [yes / no]; Cyanosis: [yes / no]; Clubbing: [yes / no] (Explicit yes/no for edema required for Group II consideration.)

Qualifying Blood Gas Study Results

(Enter all qualifying tests with exact dates, test types, conditions, and numeric results. Do not infer conditions such as room air or at rest unless explicitly documented.)

Date	Test Type	Performing Entity	Conditions	Results
[MM/DD/YYYY]	[ABG / spot oximetry / overnight oximetry / PSG titration oximetry]	[Clinic / hospital / IDTF / lab] (Not DME supplier)	[Rest / Exercise / Sleep]; [Awake / Asleep]; [Room air / Oxygen at X L/min via device]	[PaO₂ = X mmHg]; [SpO₂ = X%]; (For overnight: baseline mean, nadir, recorded duration)

Exercise Qualification: (Include only if qualifying via exercise desaturation. All three tests must be from same session.)

Date	Protocol	Test	Conditions	Result	Oxygen (if used)
[MM/DD/YYYY]	[6MWT / treadmill / hallway walk]	Rest without oxygen	Rest; Room air; Awake	SpO₂ = [X]%	—
[Same date]		Exercise without oxygen (qualifying)	Exercise; Room air; Awake	SpO₂ = [X]%	—
[Same date]		Exercise with oxygen	Exercise; On oxygen	SpO₂ = [X]%	[X] L/min via [device]

Validity Confirmations: (Include all that apply.)

• [Test timing] Test performed at time of need. (If hospital-related: discharge date [MM/DD/YYYY], test date [MM/DD/YYYY].)
• [Qualified entity] Testing performed by [clinic/hospital/IDTF/lab], not by DME supplier.
• [Exercise confirmation] All three tests performed in same session; oxygen improved exercise hypoxemia. (Include only if exercise qualification.)
• [Overnight oximetry confirmation] Stand-alone overnight oximetry with tamper-proof device; recorded duration [X] hours. (Include only if home overnight oximetry.)
• [OSA treatment confirmation] OSA adequately treated; qualifying oximetry occurred during appropriate titration study. (Include only if OSA present and sleep testing used.)

Attestation: I reviewed the qualifying test results from [MM/DD/YYYY], with numeric values documented in this note and/or attached reports.

Coverage Qualification Determination

Medicare Oxygen Group: [Group I hypoxemia / Group II borderline hypoxemia with qualifying comorbidity / Group III normoxemic covered indication / Does not meet coverage criteria]

Criteria Mapping: (Include applicable items; do not make determinations without numeric results and documented test conditions.)

• Resting room-air SpO₂ = [X]% on [date] → [meets / does not meet] Group I threshold (≤88%)
• Resting room-air PaO₂ = [X] mmHg on [date] → [meets / does not meet] Group I threshold (≤55 mmHg)
• Exercise desaturation SpO₂ = [X]% during [protocol] on [date]; improved to [X]% on [X] L/min → supports ambulatory oxygen
• Sleep-related desaturation: SpO₂ [nadir/mean] = [X]% during [overnight oximetry / PSG] on [date] → [meets / does not meet] nocturnal oxygen criteria
• Group II comorbidity: [Dependent edema/CHF / Pulmonary hypertension/cor pulmonale / Erythrocytosis (Hct X%)] documented [date] → supports Group II qualification
• Group III indication: [Specific normoxemic covered indication] documented [date] → supports Group III qualification

[Non-coverage scenario statement] (If applicable, explicitly address why criteria are not met—e.g., dyspnea without documented hypoxemia, SpO₂ above threshold without qualifying comorbidity.)

Oxygen Prescription

Equipment:

• Stationary oxygen system: [yes / no]
• Portable oxygen system: [yes / no]; Portability justification: [Mobility status and ADL-related need] (Include justification only if portable ordered.)
• Delivery interface: [Nasal cannula / Mask / Other]; Humidification: [yes / no]; Conserving device: [yes / no]

Flow Rates:

• At rest (awake): [X] L/min
• With exertion: [X] L/min (Define exertion: [ambulation / ADLs / other])
• During sleep: [X] L/min
• Target SpO₂: [X–X]%

Frequency/Duration: [Continuous / With exertion only / During sleep only / Other pattern]; Length of need: [X months / Chronic-lifetime]

Safety Counseling Provided: [Topics addressed] (e.g., fire safety, no smoking/open flames, tubing management/fall prevention, equipment use, caregiver training)

Follow-Up Plan

• [Clinical reassessment plan] (Include oxygen titration plan and reassessment after exacerbations.)
• [Continued coverage retest] Repeat qualifying test scheduled in days 61–90 window: [date range]; follow-up visit: [date] (Include only for Group II/III requiring retesting.)
• Status: Draft—pending qualifying retest. Final oxygen order will not be issued until retest completed and criteria documented. (Include only if continued coverage requirements not yet met.)

Face-to-Face Encounter Documentation

(Include this section when the ordered oxygen HCPCS code requires F2F and WOPD; omit if not applicable.)

• F2F encounter date: [MM/DD/YYYY]
• Primary condition leading to oxygen need: [Condition]
• Key subjective findings: [Symptoms and limitations attributable to hypoxemia]
• Key objective findings: [Vitals, oximetry/ABG results, pertinent exam features]
• Qualifying study: Reviewed/evaluated on [MM/DD/YYYY]
• WOPD readiness: Complete order will be signed/dated before delivery; supporting documentation is in the medical record.

Signature

Treating Practitioner Signature: [Signature] [Date/Time]

Reviewed Documents: [List attached test reports with dates] (e.g., ABG report [date], overnight oximetry download [date], PSG titration summary [date])

Missing Information: (If qualifying test results or required values are unavailable, indicate missing elements—e.g., "[SpO₂ value missing]", "[Test date not provided]"—and do not finalize coverage determination until complete.)