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Oximeters

Revised: 04-03-2014

  • Overview
  • Eligible Providers
  • Eligible Recipients
  • Covered Services
  • Noncovered Services
  • Authorization
  • Billing
  • Overview

    Oximeters are used to measure a recipient’s blood oxygen saturation levels.

    Eligible Providers

  • • Medical suppliers
  • • Hospitals
  • • Indian Health Services
  • • Federally Qualified Health Center
  • • Rural Health Clinic
  • TPL and Medicare

    Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare in order to assist recipients for whom MHCP is not the primary payer.

    MHCP quantity limits and thresholds apply to all recipients unless only Medicare co-insurance or deductible is requested.

    Eligible Recipients

    Oximeters are covered for all eligible MHCP recipients.

    Covered Services

    Codes: A4606, E0445
    Purchase or monthly rental of oximeters that are suitable for intermittent use or spot checks may be medically necessary:

  • • For periodically checking the oxygen saturation levels in recipients using long term oxygen
  • • For checking oxygen saturation levels of the recipient during or following a seizure
  • Short term, 24 hour or overnight continuous oximetry may be medically necessary:

  • • To evaluate nocturnal desaturation in patients with chronic respiratory disease
  • • To determine the appropriate oxygen needs of the recipient, particularly when there has been a change in the recipient’s medical condition.
  • • To evaluate the need for a sleep study
  • Monthly rental of an oximeter that is suitable for continuous use may be medically necessary:

  • • For recipients being weaned from home oxygen
  • • For infants less than 12 months of age using home oxygen
  • • For recipients with a temporary medical need to maintain oxygen saturation within a very narrow range
  • Purchase or monthly rental of an oximeter that is suitable for continuous use may be medically necessary:

  • • For recipients that require mechanical ventilation
  • • For recipients with a tracheostomy
  • • For recipients with a long-term medical need to maintain oxygen saturation within a very narrow range
  • Replacement oxygen probes are covered for recipients using oximeters.

  • • Durable probes are expected to last 6 months.
  • • Up to 5 disposable probes are covered each month (1 per week).
  • • Disposable probes may be appropriate for recipients whose age or disability prevents them from safely using durable probes.
  • • Durable probes should be used by recipients who use spot check or intermittent oximetry.
  • Noncovered Services

  • • Oximeters are not the community standard of care for monitoring recipients with asthma.
  • • Oximeters are not demonstrated to be effective for diagnosis of recipients with suspected obstructive sleep apnea.
  • • Back-up or portable oximeters are a duplication of equipment when the recipient has an oximeter. Providers should dispense equipment that can meet the recipient’s needs at home and in the community.
  • Authorization

    Authorization is required for repairs or maintenance service to recipient owned oximeters, for rental beyond 3 months of oximeters suitable for continuous use, and for all purchases of oximeters suitable for continuous use. Authorization is required for quantities of oximeter probes that exceed MHCP limits.

    Authorization is not required for rental or purchase of oximeters suitable for intermittent use.

    Authorization requests for rental or purchase of oximeters must include

  • • The recipient’s diagnosis and pertinent medical history
  • • Written plan of care that includes a step-by-step protocol to be used in case of desaturation
  • • Other equipment, such as apnea monitor, oxygen, or ventilator, that is used by the recipient and how the various equipment works together in the plan of care
  • • Expected duration of need
  • • Documentation of the specific oximeter model requested and its suitability to meet the recipient’s medical needs
  • • If an oximeter suitable for continuous use is requested, clearly document why a less costly oximeter will not meet the recipient’s needs.
  • Authorization requests for additional quantities of oxygen probes must include

  • • The recipient’s diagnosis and pertinent medical history
  • • Frequency of monitoring
  • • Expected duration of need
  • • If a durable probe is requested because replacement is required less than 6 months after dispensing, document the reason replacement is required.
  • • If more than 5 disposable probes per month are requested, document why a durable probe will not meet the recipient’s needs.
  • Refer to Non-Mobility Equipment Repairs for authorization requirements for repairs and maintenance service.

    Billing

  • • When billing for overnight oximetry, use modifiers RR and U4. Up to 2 units per month may be billed.
  • • When billing for rental or authorized purchase of an oximeter that is suitable for intermittent use, use modifier NU or RR as appropriate, and modifier U7.
  • • When billing for rental or authorized purchase of an oximeter that is suitable for continuous use, use modifiers NU or RR as appropriate.
  • • Oxygen probe(s) suitable for one month use is included with the original dispensing of all oximeters.
  • • When billing for a durable oxygen probe, use modifiers NU and U3.
  • Refer to the Billing and Documentation section on the main Equipment & Supplies page for additional information on how to bill.

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