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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

09-E0000-49

Original Effective Date: 04/15/04

Reviewed: 05/28/15

Revised: 06/15/15

Subject: Home Pulse Oximetry

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Pulse oximetry is a non-invasive method for measuring the amount of oxygen in the blood. A pulse oximeter consists of a computerized monitor and a probe that can be attached to the individual’s finger, toe, nose, or earlobe. This photoelectric instrument can provide a direct reading of the arterial oxygen saturation (Sa02) in the blood by measuring the amount of light transmitted through a translucent part of the skin.

Pulse oximetry should not be relied upon as the sole method for measurement of pulmonary function or as a method of screening or diagnosing patients with respiratory disorders, or suspected obstructive sleep apnea.

POSITION STATEMENT:

Home Pulse Oximeter Device

Use of a home pulse oximeter device (E0445) for continuous monitoring meets the definition of medical necessity when any of the following situations exist:

Pulse Oximetry Testing

Overnight pulse oximetry testing in the home meets the definition of medical necessity when the results are reliable in the home setting.

• The member’s record must document that the oximeter is preset and self sealed and cannot be adjusted by the member.

• In addition, the device must provide a printout that documents an adequate number of sampling hours, percent of oxygen saturation, and an aggregate of the results. This information must be made available when requested for medical review.

Home pulse oximetry does not meet the definition of medical necessity for the following:

BILLING/CODING INFORMATION:

HCPCS Coding:

A4606

Oxygen probe for use with oximeter device, replacement

E0445

Oximeter device for measuring blood oxygen levels non-invasively

REIMBURSEMENT INFORMATION:

Reimbursement for home pulse oximeters is limited to one year. Services in excess of these limitations are subject to medical review of documentation of medical necessity. The following information may be required documentation to support medical necessity: physician history and physical, physician’s progress notes, other laboratory studies.

LOINC Codes:

DOCUMENTATION TABLE

LOINC CODES

LOINC TIME FRAME MODIFIER CODE

LOINC TIME FRAME MODIFIER CODES NARRATIVE

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Blood gas tests

18767-4

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Pulmonary study

27896-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Refer to sections entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Home Use of Oxygen (240.2) located at cms.gov.

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Noninvasive Ear or Pulse Oximetry for Oxygen Saturation (L29236) located at fcso.com.

The following Durable Medical Equipment Regional Carrier (DMERC) Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Oxygen and Oxygen Equipment (L11446) located at cgsmedicare.com.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Oxygen, 09-E0400

OTHER:

Index terms:

Home pulse oximetry
Oximeters
Pulse oximetry

REFERENCES:

  1. American Academy of Pediatrics. Subcommittee on Obstructive Sleep Apnea Syndrome. Clinical Practice Guideline: Diagnostic and Management of Childhood Obstructive Sleep Apnea Syndrome. Pediatrics Vol. 109 No 4 April 2002.
  2. American Association for Respiratory Care. AARC Clinical Practice Guideline. Oxygen Therapy in the Home or Extended Care Facility. Respir Care 1992 Aug; 37(8): 918-922. (Accessed 06/24/09).
  3. American Association for Respiratory Care. AARC Clinical Practice Guideline. Pulse Oximetry. Respir Care. 1992; 37(8): 991-897.
  4. American Medical Association CPT Coding (current edition).
  5. Centers for Medicare and Medicaid Services (CMS), National Coverage Determination (NCD) for Home Use of OXYGEN (240.2), 10/27/93; accessed at cms.gov 04/17/15.
  6. Collop, Nancy A MD, et al. Clinical Guidelines for the Use of Unattended Portable Monitors in the diagnosis of Obstructive Sleep Apnea in Adult Patients; Portable Monitoring Task Force of the American Academy of Sleep Medicine. JCSM Journal of Clinical Sleep Medicine. Vol. 3, No. 7, 2007.
  7. ECRI Hotline Response, “Pulse Oximetry for Managing Home Oxygen Therapy” 03/17/06).
  8. ECRI Institute, Pulse Oximetry for Diagnosing Obstructive Sleep Apnea (OSA), 11/05.
  9. First Coast Service Options, Inc., LCD for Noninvasive Ear or Pulse Oximetry for Oxygen Saturation (L29236), 10/01/11; accessed at fcso.com 04/17/15.
  10. Hayes Directory of Medical Technology. Sleep Apnea Diagnosis, Adults SLEE0703.10 (07/15/99; updated 01/19/06).
  11. Hayes Directory of Medical Technology. Sleep Apnea Diagnosis, Pediatric us.slee0004.2006 (04/12/00; updated 01/19/06).
  12. Hayes, Inc., Home Sleep Studies for Diagnosis of Obstructive Sleep Apnea in Adults, 04/03, update 03/07.
  13. Kushida C, Littner M, Morgenthaler T, et al, American Academy of Sleep Medicine Practice Parameter for the Indications for Polysomnography and Related Procedures: An Update for 2005.
  14. Medicare DMERC (CGS Administrators) Local Coverage Determination for Oxygen and Oxygen Equipment (L11446), 10/31/14; accessed at cgsmedicare.com 04/17/15.
  15. Medicare DMERC (CGS Administrators) Local Coverage Article for Oxygen and Oxygen Equipment – Policy Article – Effective 2012 (A33750).
  16. National Guideline Clearinghouse. Chronic Obstructive Pulmonary Disease, (01/07).
  17. National Guideline Clearinghouse. Managing exacerbations of asthma: Expert panel report 3: guidelines for the diagnosis and management of asthma, (08/07).
  18. National Institute of Health Global Initiative for Asthma, National Heart, Long and Blue Institute (01/95).
  19. U.S. Department of Health and Human Services, National Institutes of Health. National Heart, Lung and Blood Institute. World Health Organization, Global Strategy for Asthma Management and Prevention NHLBI/WHO Workshop Report. Publication Number 95-3759 (01/95).

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 05/28/15.

GUIDELINE UPDATE INFORMATION:

04/15/04

New Medical Coverage Guideline.

04/15/06

Scheduled review; no changes in coverage statement; references updated.

08/15/07

Review, coverage statements maintained, guideline reformatted, references updated.

08/15/09

Scheduled review; no change in position statement; references updated.

08/15/09

Scheduled review; no change in position statement; references updated.

07/15/11

Revision; formatting changes.

03/15/13

Revision; Program Exception added for Medicare Advantage; references updated.

05/11/14

Revision: Program Exceptions section updated.

06/15/15

Revision; position statements and references updated.

Date Printed: June 24, 2017: 11:29 AM