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Home Oxygen

I know a lot of EDs are starting protocols to discharge patients on home oxygen due to limited bed capacity.  There are several O2 protocols available with an online search.  Here is some background info supporting those protocols that I’ve learned from hospitalist/SNFist colleagues.  

  • Home oxygen is regulated as Durable Medical Equipment (DME) rather than as a medication. It is delivered by DME companies to the patient’s home or to the ED/hospital.
  • For insurance to cover home O2, a patient needs to have SpO2 ≤88% on RA at rest or with exertion. It should be associated with a diagnosis such as Z99.81 “dependence on supplemental oxygen.” The testing can be done by an ED RN, RT, PT etc but should be documented in the physician’s note.
  • Sample documentation: “Face to face encounter for diagnoses described, specifically dependence on supplemental O2, Z99.81 related to COVID19 infection w/hypoxic respiratory failure & symptoms severe enough that pt will benefit from O2 therapy. At rest, on room air, pt’s O2 sat was [….value <89%] w/O2 at [1-4]LPM per NC saturation improved to […].”
  • Goal SpO2 is typically 90-92% as there is concern that higher levels would be associated with oxygen toxicity (perhaps this is more for COPD than COVID-19).  The maximum flow rate to discharge a patient is typically 2-4L/min though home devices can go higher.
  • Both physicians and advanced providers can order home O2 from the ED during this COVID pandemic waiver period.
  • Write a prescription “O2 per NC, rate (2L, 4L etc), frequency of use (around the clock or with exertion), duration of need (recommend 30 days), NPI number, provider signature.” Defer refills to the PMD.
  • Separately fill out a Certificate for Medical Necessity. The Certificate for Medical Necessity might be a form from CMS or a form from the local DME Company – your hospitalists will have the right local workflow
  • Patients might have a co-pay, but DME companies can provide oxygen prior to the co-pay.
  • The DME company will come to the patient’s home with supplies including at least 1 week’s worth of oxygen tanks and nasal cannula. They will educate the patient on using home O2. Restocking is typically weekly or monthly, not daily. Patients will need education that cigarettes, candles, and other sources of heat can cause oxygen to combust.
  • Oxygen delivery devices include:
    • Portable tank, similar to that used in the ED. This is most likely what an acute COVID patient will need.
      • Can be in gas or liquid form. Liquid tanks are smaller, more portable and refilled by a larger tank kept in the home.
    • Concentrator device, which filters room air to deliver higher concentrations of oxygen.
      • Electrical/battery powered and will fail if there is a power outage. Both large and smaller portable versions are used. These are for patients with more chronic needs.

Gregg Miller, MD FACEP

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