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 who meet criteria under Covered Services in the manual section.

Covered Services

Codes: A4606, E0445
MHCP covers the following oximeter equipment:

· Oximeter device for measuring blood oxygen levels noninvasively (E0445)

· Oxygen probe for use with oximeter device, replacement (A4606)

MHCP covers the following oximetry services:

· Purchases or rentals of oximeters that are suitable for periodic use or spot checks

· Purchases or rentals of oximeters that are suitable for continuous use

· Short-term, 24-hour, or overnight oximetry

· Fingertip pulse oximeters

MHCP covers purchases or rentals of oximeters that are suitable for periodic use or spot checks for the following:

· Periodically verifying oxygen saturation levels in members using long-term oxygen; or

· Verifying oxygen saturation levels for members following seizures.

MHCP covers short-term, 24-hour, or overnight oximetry for the following:

· Evaluating nocturnal desaturation in members with chronic respiratory disease; or

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

· Evaluating the need for sleep study.

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

MHCP covers rentals of oximeters that are suitable for continuous use for the following:

· Members being weaned from home oxygen; or

· 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.

MHCP covers purchases or rentals of oximeters that are suitable for continuous use for the following:

· Members that require mechanical ventilation; or

· Members with a tracheostomy; or

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

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

Replacement oxygen probes (A4606) are covered for members using oximeters when the original

item no longer functions. Durable probes are expected to last six months. Durable probes should be

used by members who use spot check or noncontinuous oximetry. MHCP covers up to five disposable probes per month. HCPCS code A4606 and modifier U3 represent durable probes. Disposable probes may be appropriate for members whose age or disability prevents them from safely using durable probes. Oxygen probes are not separately reimbursable within the same month of dispensing of oximeters.

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

· Backup or portable oximeters when the member has an oximeter as they are duplicate equipment

Authorization

Authorization is required for the following:

· Quantities over MHCP quantity limits

· Rental beyond three months of oximeters suitable for continuous use

· Purchases of oximeters suitable for continuous use

· Repairs or maintenance service to member-owned oximeters

Submit authorization to the Medical Review Agent.

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 clinical history; and

· Written plan of care that includes a step-by-step protocol to be used in case of desaturation; and

· 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; and

· Expected duration of need; and

· Documentation of the specific oximeter model requested and its suitability to meet the member’s medical needs; and

· 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 clinical history; and

· Frequency of monitoring; and

· Expected duration of need; and

· 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; and

· 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 the Non-Mobility Equipment Repairs section of the MHCP Provider Manual for authorization requirements for repairs and maintenance service.

Billing

Providers are responsible to coordinate services. Refer to the Billing Policy Overview section of Provider Basics in the MHCP Provider Manual for general billing information.

Bill oximeters using MN–ITS 837P Professional. Refer to the Billing for Durable Medical Equipment, Medical Supplies, Prosthetics and Orthotics, and Augmentative Devices MN–ITS user manual for claim instructions.

· Use modifier NU for purchases.

· Use modifier RR for rentals.

· Use modifiers RR and U4 with HCPCS code E0445 for overnight oximetry. Up to two units of E0445 RR U4 may be billed per month.

· Use modifier U7 for oximeters that are suitable for noncontinuous use.

· Use modifiers RR and U7 with HCPCS code E0445 for spot checks.

· Use modifiers NU and U8 with HCPCS code E1399 for fingertip pulse oximeters.

· Use modifiers NU and U3 with HCPCS code A4606 for durable oxygen probes.

· Do not bill HCPCS code A4606 within the same month of dispensing of oximeters.

· Fingertip pulse oximetry is noncovered by Medicare. 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.

Billing for Oximetry Table
Refer to the Billing for Oximetry Table for billing information for oximeters, and probes, and services by HCPCS codes and modifiers.

Billing for Oximetry Table

HCPCS Code	Modifier(s)	Service
E0445	NU or RR	Purchase or rental of oximeters for continuous use
E0445	RR and U4	Overnight oximetry checks
E0445	RR and U7	Spot checks
E0445	NU or RR and U7	Purchase or rental of oximeters for noncontinuous use
E1399	NU and U8	Fingertip pulse oximeters
A4606	NU and U3	Durable oxygen probes
A4606	NU	Disposable oxygen probes

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