Currentpriority healthPolicy N/A

OXYGEN AND OXYGEN SUPPLIES

This document governs payment, rental, documentation, and billing requirements for oxygen equipment and related supplies for Priority Health members (Commercial, Medicare per CMS, Medicaid per MDHHS).

Policy Summary

Payerpriority health

PolicyOXYGEN AND OXYGEN SUPPLIES

Policy CodePolicy N/A

Change TypeAdded frequency limitsremoved codes in table

Effective DateAug 25, 2025

Next Review DateN/A

Key ActionAppend required HCPCS modifiers (KX to indicate policy criteria met) on claims; authorization and medical necessity remain required.

SourceLink

POLICY UPDATE CHANGES

Added 'Frequency limits' section to outline limits that align with industry standards and limits set by CHAMPS.

Removal of codes in table under the frequency limits section.

5 yearsRUL (equipment)

36 monthsrental reimbursement period

months 37-60supplier responsibility

3 monthsmax contents delivered

1 unitbillable contents per month

Oxygen Equipment Coverage Criteria

Policy Summary

Payerpriority health

PolicyOXYGEN AND OXYGEN SUPPLIES

Policy CodePolicy N/A

Change TypeAdded frequency limitsremoved codes in table

Effective DateAug 25, 2025

Next Review DateN/A

Key ActionAppend required HCPCS modifiers (KX to indicate policy criteria met) on claims; authorization and medical necessity remain required.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Oxygen equipment coverage criteria

Covered when the following coverage, rental, contents, billing, and documentation requirements are met:

Coverage applies to oxygen equipment, rental, accessories, and contents per policy

Rental period: Reimbursement for oxygen equipment is limited to 36 monthly rental payments; supplier must continue to provide the equipment without additional payment for months 37-60; months 61+ the member may elect new equipment starting a new 36-month rental period; new 36-month rental period may begin if equipment is damaged beyond repair, stolen/lost, or there is a break in need of at least 60 days.

Ownership and payment: Rented oxygen equipment is payable; purchased oxygen equipment is non-covered.

Included accessories and supplier obligations: Accessories (e.g., A4608, A4615, A4616, A4617, A4619, A4620, A7525, A9900, E0455, E0555, E0580, E1353, E1355) are included in the allowance for rented oxygen equipment; supplier must provide any accessory ordered by the treating practitioner. Initial 36 months includes payment for accessories, delivery, back-up equipment, maintenance and repairs.

Reasonable Useful Lifetime (RUL): RUL for oxygen equipment is 5 years from the initial date of service; after RUL there is no separate payment for accessories or repairs (special rule: if gaseous or liquid oxygen used during the 36th month, payment can continue for oxygen contents).

Oxygen contents limits: Payment for stationary and portable contents is included in payment for stationary equipment; no payment for contents in a month when stationary equipment payment is made; a maximum of 3 months of oxygen contents may be delivered at one time; no more than 1 unit for stationary contents and 1 unit for portable contents per month are billable.

Billing and frequency rules: Capped rental devices must be billed with a date span that encompasses the month being billed ('from' = furnished date; 'to' = last date of the span); claims with overlapping dates of service will be denied; supplies billed for a date span must follow the same 'From'/'To' guidelines; a calendar month is from a day in one month to the corresponding day in the next month.

Laterality and units for bilateral items: To receive separate reimbursement for bilateral items, submit appropriate laterality modifiers (RT, LT) on separate lines; up to one unit per side with a maximum of two rental rates within the same calendar month.

Modifiers and documentation: Append required HCPCS modifiers: KX must be appended to indicate policy criteria met (claims without KX will deny for Commercial and Medicaid); other modifiers referenced include GA, GY, GZ and Medicare-specific modifiers N1,N2,N3,QA,QB,QE,QF,QG,QR. Follow CMS-standard documentation requirements.

HCPCS Codes, Units, and Billing Span Rules

Common oxygen equipment/accessory HCPCSHCPCS

A4608	Trans-tracheal catheters
A4615	Cannula
A4616	Tubing
A4617	Mouthpieces
A4619	Face tent
A4620	Mask
A7525	Mask
A9900	Oxygen conserving device
E0455	Oxygen tent
E0555	Humidifier

1–10 of 13

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Max units and billing span rules

Max billable contents per monthNo more than 1 unit for stationary contents and 1 unit for portable contents may be billed per month.

Maximum delivery at one timeA maximum of 3 months of oxygen contents may be delivered at any one time.

Capped rental billing spanCapped rental devices must be billed with a date span that encompasses the month being billed; the 'from' date = date item furnished and the 'to' date = last date of the span.

Overlapping service datesClaims with dates of service that overlap will result in a denial.

Supplies billed by spanSupplies billed for a date span must follow the same 'From' / 'To' date guidelines as rental devices.

Bilateral reimbursement rulesTo receive separate reimbursement for bilateral items, submit appropriate laterality modifiers (RT and LT on separate lines); up to one unit per side, maximum two rental rates within the same calendar month.

Modifiers, Authorization, and Billing Notes

Documentation Required

Append required HCPCS modifiers (KX, Medicare modifiers, GA/GY/GZ)

Append the required HCPCS modifiers on claims as follows: KX must be appended to indicate that policy criteria have been met; claims submitted without the KX modifier will deny as non-payable for Commercial and Medicaid products. Medicare-specific modifiers (N1, N2, N3, QA, QB, QE, QF, QG, QR) must be used based on the beneficiary's condition and oxygen requirements. GA, GY, and GZ modifiers are referenced; see the Provider Manual for additional information. Authorization and medical necessity requirements still apply, and an authorization does not guarantee payment if billing/coding or policy requirements are not met.

KX modifier: indicates policy criteria met; absence of KX will cause denial (Commercial, Medicaid).
Medicare-specific modifiers: N1, N2, N3, QA, QB, QE, QF, QG, QR — use as appropriate to beneficiary condition and oxygen needs.
Additional modifiers (GA, GY, GZ): referenced; consult Provider Manual for usage.
Authorization and medical necessity remain required; authorization is not a guarantee of payment.

Definitions and Useful Life

Definition

Policy scopeThis policy identifies the payment and documentation requirements associated with oxygen and oxygen equipment.

Applies toPayment, rental, documentation, and billing requirements for oxygen equipment and related supplies for Priority Health members (Commercial, Medicare per CMS, Medicaid per MDHHS).

Documentation standardsCMS standard documentation requirements apply; reference CMS guidance where specified.

Reasonable Useful Lifetime (RUL)

Reasonable Useful Lifetime (RUL)The RUL for oxygen equipment is 5 years, starting from the initial date of service.

Effect after RULAfter the 5‑year RUL, no separate payment is made for accessories or repairs to the item (per policy rules).

New rental period eligibilityMembers may elect new equipment after the RUL to start a new rental period if other criteria (e.g., damage beyond repair) are met.