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Oxygen Testing for Patients to get PORTABLE Oxygen coverage from Medicare & Medicaid
(One type of testing for O2 portable)
DO NOT USE THIS FORM AS DOCUMENTATION FOR INSURANCE COVERAGE-MUST BE IN DOCTOR PROGRESS NOTES!
Simple Pulmonary Stress Test
1. Record O2 Sat at REST AND ROOM AIR _____________
2. Record O2 Sat at AMBULATION AND ROOM AIR_________
3. Record O2 Sat at AMBULATION AND OXYGEN_____, O2 LITER FLOW_____
ALL THREE STEPS MUST BE CONDUCTED AND IN THIS ORDER WITHOUT STOPPING.
PLEASE NOTE THAT IF PATIENT IS AT REST AND ROOM AIR AND O2 SATURATION IS
88% OR LESS, THE TESTING IS CONSIDERED QUALIFYING AND NO NEED TO CONTINUE
STEPS TWO AND THREE.
******This is only for informational purposes. Please ensure that all wording (Chronic Stable State or no apparent distress) and O2 sats and LPM are in VISIT NOTES for insurance coverage purposes. Call 979-968-6680 if you have any questions. ***
Note: If patient’s O2 sat is 88% or less at REST/ROOM AIR, no need to conduct steps 2 and 3.
Notes for Medicare Coverage of Wheelchair
***Please fax recent office visit notes pertaining to the need for a WHEELCHAIR to FAX#979-859-7184.
Medicare requires the Office Visit Note or Medical Record to reflect very specific information for
A manual wheelchair for use inside the home is covered if Criteria A, B, C, D, and E are met; AND
Criterion F or G is met.
A. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one
or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing,
grooming, and bathing in customary locations in the home. A mobility limitation is one that:
B. The beneficiary’s mobility limitation cannot be sufficiently resolved by the use of an appropriately
fitted cane or walker.
C. The beneficiary’s home provides adequate access between rooms, maneuvering space, and
surfaces for use of the manual wheelchair that is provided.
D. Use of a manual wheelchair will significantly improve the beneficiary’s ability to participate in
MRADLs and the beneficiary will use it on a regular basis in the home.
E. The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in
F. The beneficiary has sufficient upper extremity function and other physical and mental capabilities
needed to safely self-propel the manual wheelchair that is provided in the home during a typical day.
Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or
absence of one or both upper extremities are relevant to the assessment of upper extremity function.
G. The beneficiary has a caregiver who is available, willing, and able to provide assistance with the
IF a Lightweight Wheelchair is prescribed Medicare stipulates the record also document:
A lightweight wheelchair is covered when a beneficiary meets both criteria (1) and (2):
1. Cannot self-propel in a standard wheelchair in the home; and
2. The beneficiary can and does self-propel in a lightweight wheelchair
If there is a Home Health/PT Evaluation for a Wheelchair that has been performed, please fax that
record for review to 979-859-7184
Please do not hesitate to contact Fayette Medical Supply for assistance at 979-968-6680.