TPL and Medicare
Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare to assist members for whom Minnesota Health Care Programs (MHCP) is not the primary payer.

MHCP quantity limits and thresholds apply to all members unless only Medicare coinsurance or deductible is requested.

Refer to the Medicare and Other Insurance section of the MHCP Provider Manual for more information.

Eligible Members

Oximeters are covered for all eligible Medical Assistance and MinnesotaCare members.

Covered Services

Codes: A4606, E0445

MHCP covers oximeters and probes for use by a member in the following:
Purchase or monthly rental of oximeters that are suitable for periodic use or spot checks may be medically necessary:

· For periodically checking the oxygen saturation levels in members using long-term oxygen.

· For checking oxygen saturation levels of the member during or following a seizure.

Fingertip pulse oximeters are purchase only and are covered with medical necessity. Use code E1399 and refer to billing instructions under Billing.

Short-term, 24-hour or overnight continuous oximetry may be medically necessary to:

· evaluate nocturnal desaturation in members with chronic respiratory disease,

· determine the appropriate oxygen needs of the member, particularly when there has been a change in the member’s medical condition or

· evaluate the need for a sleep study.

Monthly rental of an oximeter that is suitable for continuous use may be medically necessary for:

· members being weaned from home oxygen,

· infants less than 12 months old using home oxygen or

· members 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 members:

· that require mechanical ventilation,

· with a tracheostomy,

· with a long-term medical need to maintain oxygen saturation or

· with a long-term medical need to monitor cardiac activity and oxygen saturation.

Replacement oxygen probes are covered for members using oximeters.

· Durable probes are expected to last six months.

· Up to five disposable probes are covered each month (one per week).

· Disposable probes may be appropriate for members whose age or disability prevents them from safely using durable probes.

· Durable probes should be used by members who use spot check or noncontinuous oximetry.

Noncovered Services

MHCP does not cover the following:

· Oximeters for members monitoring asthma as they are not the community standard of care.

· Oximeters for members with diagnosis of suspected obstructive sleep apnea as they are not demonstrated to be effective.

· Back-up or portable oximeters when the member has an oximeter as they are duplicate equipment.

Authorization

Authorization is required for:

· Repairs or maintenance service to member-owned oximeters.

· Rental beyond three months of oximeters suitable for continuous use.

· All purchases of oximeters suitable for continuous use.

· Quantities of oximeter probes that exceed MHCP limits.

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

Authorization requests for rental or purchase of oximeters must include:

· The member’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 member 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 member’s medical needs.

· Documentation of why a less-costly oximeter will not meet the member’s needs if an oximeter suitable for continuous use is requested.

Authorization requests for additional quantities of oxygen probes must include:

· The member’s diagnosis and pertinent medical history.

· Frequency of monitoring.

· Expected duration of need.

· Documentation of the reason a replacement is required if a durable probe is requested because the replacement is required less than six months after dispensing.

· Documentation of why a durable probe will not meet the member’s needs if more than five disposable probes per month are requested.

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.

· Rental or authorized purchase of an oximeter that is suitable for noncontinuous use, use modifier NU or RR, as appropriate, and modifier U7.

· Rental or authorized purchase of an oximeter that is suitable for continuous use, use modifiers NU or RR, as appropriate.

· Fingertip pulse oximeters, use HCPCS code E1399, modifier NU and modifier U8. When billing for members covered by Medicare, include an attachment that clearly states “fingertip pulse oximeter not covered by Medicare” or add this statement under claim information in the claim note field in MN–ITS.

· Oxygen probes suitable for one-month use is included with the original dispensing of all oximeters.

· A durable oxygen probe, use modifiers NU and U3.

Refer to the Billing and Documentation section on the main Equipment and Supplies section of the MHCP Provider Manual for additional billing information.

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