CPT code 94760, 96523 ,94761, 94762 - Oximetry Services

Procedure Description


94760 Noninvasive ear or pulse oximetry for oxygen saturation, single determination


CPT Code Description

Codes with a Status Indicator of T

36598 Contrast injection(s) for radiologic evaluation of existing central venous access device, including fluoroscopy, image documentation and report


94761 Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations (e.g., during exercise)

96523 Irrigation of implanted venous access device for drug delivery systems 


Coverage Indications, Limitations, and/or Medical Necessity

    Pulse oximetry provides a simple, accurate, and noninvasive technique for the continuous or intermittent monitoring of arterial oxygen saturation. A small lightweight device attaches to the finger or toe and directs through the nailbed two wavelengths of light; a photodetector measures absorption. Arterial pulsation is used to gate the signal to the arterial component of blood contained within the nailbed.

    Ear oximetry is a noninvasive method for evaluating arterial oxygenation. Ear oximeters are commonly used in sleep studies.

    Single and Multiple Determinations (94760, 94761):

    Ear or pulse oximetry for oxygen saturation (CPT Codes 94760, 94761) will be considered medically necessary when the patient has a condition resulting in hypoxemia and there is a need to assess the status of a chronic respiratory condition, supplemental oxygen requirements and/or a therapeutic regimen (see ICD-10 Codes That Support Medical Necessity).

    Continuous Overnight Monitoring (94762):

    Ear or pulse oximetry for oxygen saturation by continuous overnight monitoring (CPT code 94762) will be considered medically necessary in the following circumstances (see ICD-10 Codes That Support Medical Necessity):


        The patient must have a condition for which intermittent arterial blood gas sampling is likely to miss important variations, and

        The patient must have a condition resulting in hypoxemia and there is a need to assess supplemental oxygen requirements and/or a therapeutic regimen.

Oximetry measures oxygen saturation using a non-invasive probe. This is done by measuring light absorption of oxygenated hemoglobin and total hemoglobin in arterial blood.

Medicare will allow payment for oximetry when accompanied by an appropriate ICD-9-CM code for a pulmonary disease(s) which is commonly associated with oxygen desaturation. Routine use of oximetry is non-covered.

Medically necessary reasons for pulse oximetry include:

• Patient exhibits signs or symptoms of acute respiratory dysfunction such as:
  • Tachypnea.
  • Dyspnea.
  • Cyanosis.
  • Respiratory distress.
  • Confusion.
  • Hypoxia.
• Patient has chronic lung disease, severe cardiopulmonary disease or neuromuscular disease involving the muscles of respiration, and oximetry is needed for at least one of the following reasons:
  • Initial evaluation to determine the severity of respiratory impairment.
  • Evaluation of an acute change in condition.
  • Evaluation of exercise tolerance in a patient with respiratory disease.
  • Evaluation to establish medical necessity of oxygen therapeutic regimen.
• Patient has sustained severe multiple trauma or complains of acute severe chest pain.
• Patient is under treatment with a medication with known pulmonary toxicity, and oximetry is medically necessary to monitor for potential adverse effects of therapy.
• 
  

These services may be performed in the home or office by a provider or by an independent diagnostic testing facility.

The results of tests performed by a durable medical equipment supplier to qualify patients for home oxygen service are not covered.

Overnight Oximetry (94762) is considered medically necessary when performed for any of the following circumstances:

• The patient has a condition for which intermittent arterial blood gas sampling is likely to miss important variations.
• The patient has a condition resulting in hypoxemia and there is a need to assess supplemental oxygen requirements and/or a therapeutic regimen.

Compliance with the provisions in this LCD may be subject to monitoring by postpayment data analysis and subsequent medical review.

LCD Individual Consideration

Additional payment may be allowed for oximetric determinations exceeding the parameters described in the “Utilization Guidelines” section below on an “individual consideration” basis. The “LCD Individual Consideration” procedure is described in the related Article.

 Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

• Safe and effective.
• Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
• Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
  • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
  • Furnished in a setting appropriate to the patient’s medical needs and condition.
  • Ordered and furnished by qualified personnel.
  • One that meets, but does not exceed, the patient’s medical need.
  • At least as beneficial as an existing and available medically appropriate alternative.
  • 
    

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

12X, 13X, 18X, 21X, 22X, 23X, 71X, 73X, 74X, 75X, 77X, 85X

Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X is effective for dates of service on or after April 1, 2010.

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes

Note:	Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
94760©	Measure blood oxygen level
94761©	Measure blood oxygen level
94762©	Measure blood oxygen level

Coding and Reimbursement

The Current Procedural Terminology (CPT) identifies three codes and descriptors that may be reported for pulse oximetry 94760, 94761, and 94762.

The code descriptions and the approximate Medicare reimbursement are as follows:

94760, noninvasive ear or pulse oximetry for oxygen saturation; single determination: simple pulse oximetry study with one Sao2 (Spo2) value documented. The 2009 Medicare relative value unit (RVU) is 0.08, which means that the geographically unadjusted allowable rate is approximately $2.89. 

94761, noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations (eg, during exercise). Multiple pulse oximetry with several Sao2 (Spo2) determinations reported usually taken while the patient is sitting, standing, and walking. The 2009 Medicare RVU is 0.16, which means that the geographically unadjusted allowable rate is approximately $5.77

Pulse oximetry is considered a technical service involving no physician work component, and such technical services are not payable to physicians or nonphysician providers in any facility setting. Medicare designates codes 94760 and 94761 as “T” status codes, so that reimbursement for these two pulse oximetry services are always bundled with and included with the payment of a primary service.4 If the patient only receives either single (94760) or multiple (94761) oximetry in the office setting and does not receive any other services by a physician or nonphysician provider on the same day, these may be reported for reimbursement. When an office visit is the primary service provided, pulse oximetry is not reported, but the level of Evaluation and Management (E/M) service reported may be impacted by the inclusion of pulse oximetry as part of the medical decision-making portion of the E/M encounter.

Likewise, these codes are considered included as an element of other primary procedures such as a simple pulmonary stress test (94620) and respiratory therapy services (G0237, G0238, and G0239).5 Conversely, 94762 achieves “A” status, allowing for separate reimbursement when coverage regulations are met. Under certain circumstances, 94762 may be separately payable to a physician (see “Indications, Medical Necessity, and Documentation”).

The Correct Coding Initiative (CCI) applies to CPT codes 94760, 94761, and 94762. The CCI lists CPT codes that are bundled into other services and not separately reported. The CCI includes pulse oximetry in all critical care services (99289 to 99300).5 CCI also bundles pulse oximetry into other nonpulmonary services such as cardiac stress testing and procedures requiring anesthesia or moderate sedation. 

While Medicare considers pulse oximetry as incidental when provided with a primary service, other payers may not. Although Medicare guidelines and coding methodologies are generally accepted by many commercial insurers, it is not unusual for some commercial insurers to apply varying reimbursement methodologies, particularly as these apply to “bundling.”

Bundling occurs when a payer combines two or more services/procedures, allowing the physician to report only the most comprehens ve service/procedure regardless of modifier usage. Some commercial payers consider the pulse oximetry codes 94760, 61, and 94762 to be included in all E/M services, for example, outpatient office visits (99201 to 99215) or outpatient consultations (99241 to 99245) and therefore not separately payable. Some commercial payers may adapt methodologies where “unbundling” and adding a modifier may be suggested, therefore adding to the level of reimbursement.6 Inasmuch as reimbursement from commercial insurers may vary dramatically and is con stantly changing, it is recommended that individual coverage be researched to determine each patient’s benefit level.

94760 (Noninvasive ear or pulse oximetry for oxygen saturation; single determination) and 94761 (Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations {e.g., during exercise}) bundles with 99201-99205 (Office or other outpatient services-new patient evaluation and management services), 99211-99215 (Office or other outpatient services-established patient evaluation and management services), 99217-99220 (Initial observation care evaluation and management services), 99221-99233 (Initial and subsequent hospital care evaluation and management services), 99234-99239 (Observation or inpatient care services and discharge evaluation and management services), 99241-99245 (Office or other outpatient consultations), 99251-99263 (Initial and follow-up inpatient consultation evaluation and management services) 99271-99275 (Confirmatory consultation evaluation and management services) 99281-99285 (Emergency department evaluation and management services), 99301-99316 (Comprehensive nursing facility assessments, new, subsequent or discharge evaluation and management services), 99321-99333 (Domiciliary, rest home {e.g., boarding home} or custodial care services), 99341-99350 (Home visit evaluation and management services) and 99381-99387 (Preventive medicine services-new patient) and 99391-99397 (Preventive medicine services-established patient).

Rationale for Edit:

Anthem Midwest bundles 94760 and 94761 with 99201-99205, 99211-99215, 99217-99220, 99221- 99233, 99234-99239, 99241-99245, 99251-99263 99271-99275, 99281-99285, 99301-99316, 99321- 99333, 99341-99350, 99381-99387 or 99391-99397. Based on the 2003 CPT manual, "If a separate identifiable Evaluation and Management service is performed, the appropriate E/M service code should be reported in addition to 94010-94799. Therefore, if 94760 or 94761 is submitted with 99201-99205, 99211-99215, 99217-99220, 99221-99233, 99234-99239, 99241-99245, 99251-99263, 99271-99275, 99281-99285, 99301-99316, 99321-99333, 99341-99350, 99381-99387 or 99391-99397-- only 99201- 99205, 99211-99215, 99217-99220, 99221-99233, 99234-99239, 99241-99245, 99251-99263, 99271- 99275, 99281-99285, 99301-99316, 99321-99333, 99341-99350, 99381-99387 or 99391-99397 will reimburse

If a separate identifiable service requiring an evaluation and management service is performed along with pulse oximetry (94760 or 94761) then this maybe submitted one of two ways. Append the modifier 25 to the evaluation and management service (99201-25-99205-25, 99211-25-99215-25, 99217-25-99220-25, 99221-25-99233-25, 99234-25-99239-25, 99241-25-99245-25, 99251-25-99263-25, 99271-25-99275-25, 99281-25-99285-25, 99301-25-99316-25, 99321-25-99333-25, 99341-25-99350-25, 99381-25-99387-25

or 99391-25-99397-25) or add modifier 59 to the pulse oximetry (94760-59 or 94761-59)--then both the pulse oximetry and the evaluation and management services will reimburse separately. 

If on appeal, it is documented that a pulse oximetry was performed and a separate identifiable service requiring an evaluation and management service was provided --then both the pulse oximetry and the evaluation and management services may reimburse separately. Anthem Midwest bundles 94760 and 94761 with 99141 and 99142. Based on the 2003 CPT manual, "Conscious sedation includes performance and documentation of pre- and post-sedation evaluation of the  patient, administration of the sedation and/or analgesic agent(s), and monitoring of cardiorespiratory function {i.e., pulse oximetry, cardiorespiratory monitor, and blood pressure})." Therefore, if 94760 or 94761 is submitted with 99141 or 99142--only 99141 or 99142 will reimburse.

Anthem Midwest bundles 94762 as incidental with 95805-95811. Based on the Correct Coding Edits for Comprehensive Codes 90000-99999, code 94762 is listed as a component code to codes 95805-95811. 

Therefore, if 94762 is submitted with 95805-95811--only 95805-95811 will reimburse. 

Anthem Midwest bundles 94760-94762 as incidental to all anesthesia CPT codes 00100-01999. Based on the 2003 CPT Manual, Anesthesia Guidelines, " The reporting of anesthesia services is appropriate by or under the responsible supervision of a physician These services may include but are not limited to general, regional, supplementation of local anesthesia, or other supportive services in order to afford the patient the anesthesia care deemed optimal by the anesthesiologist during any procedure. These services include the usual preoperative and postoperative visits, the anesthesia care during the procedure, the administration of fluids and/or blood and the usual monitoring services (e.g., ECG, temperature, blood pressure, oximetry, capnography, and mass spectrometry)." Therefore, if 94760-94762 is submitted with 00100-01999-- only the anesthesia services will reimburse.



REIMBURSEMENT GUIDELINES

All codes published on the NPFS Relative Value File are assigned a status code. The status code indicates whether the code is separately payable if the service is covered. Per the public use file that accompanies the NPFS Relative Value File, the following is stated for status indicator "T":

"There are RVUs and payment amounts for these services, but they are only paid if there are no other services payable under the physician fee schedule billed on the same date by the same provider. If any other services payable under the physician fee schedule are billed on the same date by the same provider, these services are bundled into the physician services for which payment is made."

Consistent with CMS, Oxford considers Current Procedural Terminology (CPT®) and Healthcare Common Procedural Coding System (HCPCS) codes with a status indicator of “T” according to the CMS NPFS bundled into any other service assigned a status indicator of “A” or “R” provided, on the same date by the Same Individual Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, for which payment is made. Modifier overrides will not prevent codes with a status indicator of “T” from bundling into other services.

Per the public use file that accompanies the NPFS Relative Value File, the following is stated for status indicator of “A”: “Active Code. These codes are paid separately under the physician fee schedule, if covered. There will be RVUs for
codes with this status. The presence of an ‘A’ indicator does not mean that Medicare has made a national coverage
determination regarding the service; carriers remain responsible for coverage decisions in the absence of a national Medicare policy.”


The following is stated for status indicator of “R”:

“Restricted Coverage. Special coverage instructions apply. If covered, the service is carrier priced.”


Note: The majority of codes to which this indicator will be assigned are the alpha-numeric dental codes, which begin with "D." We are assigning the indicator to a limited number of CPT codes which represent services that are covered only in unusual circumstances.



QUESTIONS AND ANSWERS

1 Q: Why does this policy not address all codes that the NPFS identifies as T status?

A: Codes from the NPFS with a status of "T", but otherwise addressed in other Oxford reimbursement policies, are not included in this policy.

2 Q: Will Oxford reimburse two codes with a status indicator of T when reported for the same patient by the Same Individual Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional on the same date of service?


A: No, Oxford will consider reimbursement for the code with a status indicator of T with the highest RVU and payment for the other as bundled and not separately reimbursed only when no other service reported with a status indicator of A or R. If reported with another service with a status indicator of A or R, Oxford will bundle both codes with a status indicator of T into the reimbursement for the payable service code and will not be separately reimbursed.

PULSE OXIMETER - Medicaid

Definition A pulse oximeter is a noninvasive device that measures arterial oxygen saturation levels and pulse rate. The device consists of a sensor attached to the patient's finger or ear lobe that is linked to a processing unit that delivers a read-out.


Standards of Coverage

Pulse oximeter may be covered:

* For beneficiaries 21 or over as a diagnostic tool for short-term rental (one month) if ordered for oxygen or ventilator weaning in the home.

* For beneficiaries under 21:

* As a diagnostic tool for short-term rental (one month) when there are suspected desaturations during sleep, stress, or
feeding.

* Up to six months with a diagnosis requiring oxygen use.

* Up to six months for beneficiaries with a tracheostomy.

Documentation Documentation must be less than 90 days old and include the following:

* Diagnosis/medical condition related to the need for the unit.

* Treatment plan addressing what is to be done for abnormal readings.

* Current oxygen orders, if applicable.

* For coverage beyond the initial six-month period, an evaluation by an appropriate pediatric subspecialist (e.g., pediatric pulmonologist, pediatric cardiologist, neurologist, ENT, or pediatric internist) is required under the CSHCS program.




PA Requirements PA is not required when the Standards of Coverage are met, the beneficiary is under 21, and has one of the following diagnoses:


* Tracheostomy (Artificial Opening Status)

* Tracheostomy (Attention to Artificial Openings) PA is required:

* For all beneficiaries over the age of 21.

* When the Standards of Coverage are not met. Payment Rules A pulse oximeter is a capped rental item and is inclusive of the following:

* All accessories needed to use the unit (e.g., nondisposable infant or adult oximeter probes, cables, etc.).

* Education on the proper use and care of the equipment.

* Routine servicing and all necessary repairs or replacements to make the unit functional.

* Periodic downloading of recorded data.


If needed for continuous use beyond the 10 months of rental, the item is considered purchased and necessary repairs and/or replacements of accessories are separately reimbursable if not covered under the manufacturer warranty. Replacement of one non-disposable probe annually is separately reimbursable without prior authorization.

ICD-10 Codes that Support Medical Necessity
   
    Single and Multiple Determinations (94760, 94761):
   
    C34.00 Malignant neoplasm of unspecified main bronchus
    C34.01 Malignant neoplasm of right main bronchus
    C34.02 Malignant neoplasm of left main bronchus
    C34.10 Malignant neoplasm of upper lobe, unspecified bronchus or lung
    C34.11 Malignant neoplasm of upper lobe, right bronchus or lung
    C34.12 Malignant neoplasm of upper lobe, left bronchus or lung
    C34.2 Malignant neoplasm of middle lobe, bronchus or lung
    C34.30 Malignant neoplasm of lower lobe, unspecified bronchus or lung
    C34.31 Malignant neoplasm of lower lobe, right bronchus or lung
    C34.32 Malignant neoplasm of lower lobe, left bronchus or lung
    C34.80 Malignant neoplasm of overlapping sites of unspecified bronchus and lung
    C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung
    C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung
    C34.90 Malignant neoplasm of unspecified part of unspecified bronchus or lung
    C34.91 Malignant neoplasm of unspecified part of right bronchus or lung
    C34.92 Malignant neoplasm of unspecified part of left bronchus or lung
    I01.8 Other acute rheumatic heart disease
    I09.81 Rheumatic heart failure
    I11.0 Hypertensive heart disease with heart failure
    I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
    I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease
    I16.0 Hypertensive urgency
    I16.1 Hypertensive emergency
    I16.9 Hypertensive crisis, unspecified
    I50.1 Left ventricular failure
    I50.20 Unspecified systolic (congestive) heart failure
    I50.21 Acute systolic (congestive) heart failure
    I50.22 Chronic systolic (congestive) heart failure
    I50.23 Acute on chronic systolic (congestive) heart failure
    I50.30 Unspecified diastolic (congestive) heart failure
    I50.31 Acute diastolic (congestive) heart failure
    I50.32 Chronic diastolic (congestive) heart failure
    I50.33 Acute on chronic diastolic (congestive) heart failure
    I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure
    I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure
    I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure
    I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure
    I50.9 Heart failure, unspecified
    J43.0 Unilateral pulmonary emphysema [MacLeod's syndrome]
    J43.1 Panlobular emphysema
    J43.2 Centrilobular emphysema
    J43.8 Other emphysema
    J43.9 Emphysema, unspecified
    J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection
    J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
    J44.9 Chronic obstructive pulmonary disease, unspecified
    J45.20 Mild intermittent asthma, uncomplicated
    J45.21 Mild intermittent asthma with (acute) exacerbation
    J45.22 Mild intermittent asthma with status asthmaticus
    J45.30 Mild persistent asthma, uncomplicated
    J45.31 Mild persistent asthma with (acute) exacerbation
    J45.32 Mild persistent asthma with status asthmaticus
    J45.40 Moderate persistent asthma, uncomplicated
    J45.41 Moderate persistent asthma with (acute) exacerbation
    J45.42 Moderate persistent asthma with status asthmaticus
    J45.50 Severe persistent asthma, uncomplicated
    J45.51 Severe persistent asthma with (acute) exacerbation
    J45.52 Severe persistent asthma with status asthmaticus
    J45.901 Unspecified asthma with (acute) exacerbation
    J45.902 Unspecified asthma with status asthmaticus
    J45.909 Unspecified asthma, uncomplicated
    J45.990 Exercise induced bronchospasm
    J45.991 Cough variant asthma
    J45.998 Other asthma
    J47.1 Bronchiectasis with (acute) exacerbation
    J47.9 Bronchiectasis, uncomplicated
    J80 Acute respiratory distress syndrome
    J84.10 Pulmonary fibrosis, unspecified
    J95.1 Acute pulmonary insufficiency following thoracic surgery
    J95.2 Acute pulmonary insufficiency following nonthoracic surgery
    J95.3 Chronic pulmonary insufficiency following surgery
    J95.821 Acute postprocedural respiratory failure
    J95.822 Acute and chronic postprocedural respiratory failure
    J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia
    J96.01 Acute respiratory failure with hypoxia
    J96.02 Acute respiratory failure with hypercapnia
    J96.10 Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia
    J96.11 Chronic respiratory failure with hypoxia
    J96.12 Chronic respiratory failure with hypercapnia
    J96.20 Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia
    J96.21 Acute and chronic respiratory failure with hypoxia
    J96.22 Acute and chronic respiratory failure with hypercapnia
    J98.4 Other disorders of lung
    R06.00 Dyspnea, unspecified
    R06.02 Shortness of breath
    R06.09 Other forms of dyspnea
    R06.2 Wheezing
    R06.3 Periodic breathing
    R06.81 Apnea, not elsewhere classified
    R06.82 Tachypnea, not elsewhere classified
    R06.83 Snoring
    R06.89 Other abnormalities of breathing
    Group 2 Paragraph
    Continuous Overnight Monitoring (94762):
    Group 2 Codes
    C34.00 Malignant neoplasm of unspecified main bronchus
    C34.01 Malignant neoplasm of right main bronchus
    C34.02 Malignant neoplasm of left main bronchus
    C34.10 Malignant neoplasm of upper lobe, unspecified bronchus or lung
    C34.11 Malignant neoplasm of upper lobe, right bronchus or lung
    C34.12 Malignant neoplasm of upper lobe, left bronchus or lung
    C34.2 Malignant neoplasm of middle lobe, bronchus or lung
    C34.30 Malignant neoplasm of lower lobe, unspecified bronchus or lung
    C34.31 Malignant neoplasm of lower lobe, right bronchus or lung
    C34.32 Malignant neoplasm of lower lobe, left bronchus or lung
    C34.80 Malignant neoplasm of overlapping sites of unspecified bronchus and lung
    C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung
    C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung
    C34.90 Malignant neoplasm of unspecified part of unspecified bronchus or lung
    C34.91 Malignant neoplasm of unspecified part of right bronchus or lung
    C34.92 Malignant neoplasm of unspecified part of left bronchus or lung
    G47.30 Sleep apnea, unspecified
    I01.8 Other acute rheumatic heart disease
    I09.81 Rheumatic heart failure
    I11.0 Hypertensive heart disease with heart failure
    I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
    I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease
    I16.0 Hypertensive urgency
    I16.1 Hypertensive emergency
    I16.9 Hypertensive crisis, unspecified
    I50.1 Left ventricular failure
    I50.20 Unspecified systolic (congestive) heart failure
    I50.21 Acute systolic (congestive) heart failure
    I50.22 Chronic systolic (congestive) heart failure
    I50.23 Acute on chronic systolic (congestive) heart failure
    I50.30 Unspecified diastolic (congestive) heart failure
    I50.31 Acute diastolic (congestive) heart failure
    I50.32 Chronic diastolic (congestive) heart failure
    I50.33 Acute on chronic diastolic (congestive) heart failure
    I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure
    I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure
    I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure
    I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure
    I50.9 Heart failure, unspecified
    J43.0 Unilateral pulmonary emphysema [MacLeod's syndrome]
    J43.1 Panlobular emphysema
    J43.2 Centrilobular emphysema
    J43.8 Other emphysema
    J43.9 Emphysema, unspecified
    J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection
    J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
    J44.9 Chronic obstructive pulmonary disease, unspecified
    J45.20 Mild intermittent asthma, uncomplicated
    J45.21 Mild intermittent asthma with (acute) exacerbation
    J45.22 Mild intermittent asthma with status asthmaticus
    J45.30 Mild persistent asthma, uncomplicated
    J45.31 Mild persistent asthma with (acute) exacerbation
    J45.32 Mild persistent asthma with status asthmaticus
    J45.40 Moderate persistent asthma, uncomplicated
    J45.41 Moderate persistent asthma with (acute) exacerbation
    J45.42 Moderate persistent asthma with status asthmaticus
    J45.50 Severe persistent asthma, uncomplicated
    J45.51 Severe persistent asthma with (acute) exacerbation
    J45.52 Severe persistent asthma with status asthmaticus
    J45.901 Unspecified asthma with (acute) exacerbation
    J45.902 Unspecified asthma with status asthmaticus
    J45.909 Unspecified asthma, uncomplicated
    J45.990 Exercise induced bronchospasm
    J45.991 Cough variant asthma
    J45.998 Other asthma
    J47.1 Bronchiectasis with (acute) exacerbation
    J47.9 Bronchiectasis, uncomplicated
    J80 Acute respiratory distress syndrome
    J84.10 Pulmonary fibrosis, unspecified
    J95.1 Acute pulmonary insufficiency following thoracic surgery
    J95.2 Acute pulmonary insufficiency following nonthoracic surgery
    J95.3 Chronic pulmonary insufficiency following surgery
    J95.821 Acute postprocedural respiratory failure
    J95.822 Acute and chronic postprocedural respiratory failure
    J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia
    J96.01 Acute respiratory failure with hypoxia
    J96.02 Acute respiratory failure with hypercapnia
    J96.10 Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia
    J96.11 Chronic respiratory failure with hypoxia
    J96.12 Chronic respiratory failure with hypercapnia
    J96.20 Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia
    J96.21 Acute and chronic respiratory failure with hypoxia
    J96.22 Acute and chronic respiratory failure with hypercapnia
    J98.4 Other disorders of lung
    R06.00 Dyspnea, unspecified
    R06.02 Shortness of breath
    R06.09 Other forms of dyspnea
    R06.2 Wheezing
    R06.3 Periodic breathing
    R06.81 Apnea, not elsewhere classified
    R06.82 Tachypnea, not elsewhere classified
    R06.83 Snoring
    R06.89 Other abnormalities of breathing

ICD-9-CM Codes That Support Medical Necessity

The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 94760 and 94761:

Covered for:

011.00–011.06	Tuberculosis of lung infiltrative
011.10–011.16	Tuberculosis of lung nodular
011.20–011.26	Tuberculosis of lung with cavitation
011.30–011.36	Tuberculosis of bronchus
011.40–011.46	Tuberculous fibrosis of lung
011.50–011.56	Tuberculous bronchiectasis
011.60–011.66	Tuberculous pneumonia (any form)
011.70–011.76	Tuberculous pneumothorax
011.80–011.86	Other specified pulmonary tuberculosis
011.90–011.96	Unspecified pulmonary tuberculosis
012.80–012.86	Other specified respiratory tuberculosis
020.3–020.5	Plague
021.2	Pulmonary tularemia
039.1	Pulmonary actinomycotic infection
052.1	Varicella (hemorrhagic) pneumonitis
073.0	Ornithosis with pneumonia
130.4	Pneumonitis due to toxoplasmosis
135	Sarcoidosis
136.3	Pneumocystosis
162.0	Malignant neoplasm of trachea
162.2–162.5	Malignant neoplasm of trachea, bronchus or lung
162.8–162.9	Malignant neoplasm of trachea, bronchus or lung
197.0	Secondary malignant neoplasm of lung
277.02	Cystic fibrosis with pulmonary manifestations
277.6	Other deficiencies of circulating enzymes
293.0	Delirium due to conditions classified elsewhere
298.9	Unspecified psychosis
335.20–335.21	Motor neuron disease
357.0	Acute infective polyneuritis
358.00–358.01	Myasthenia gravis
413.9	Other and unspecified angina pectoris
415.0	Acute cor pulmonale
415.11–415.12	Pulmonary embolism and infarction
415.19	Other pulmonary embolism and infarction
416.0–416.2	Chronic pulmonary heart disease
416.8–416.9	Chronic pulmonary heart disease
428.0–428.1	Heart failure
428.9	Heart failure
464.00–464.01	Acute laryngitis
464.10–464.11	Acute tracheitis
464.20–464.21	Acute laryngotracheitis
464.30–464.31	Acute epiglottitis
464.4	Croup
464.50–464.51	Supraglottitis unspecified
466.0	Acute bronchitis
466.11	Acute bronchiolitis due to respiratory syncytial virus (rsv)
466.19	Acute bronciolitis due to other infectious organisms
478.70–478.71	Other diseases of larynx, not else where classified
478.74–478.75	Other diseases of larynx, not else where classified
478.79	Other diseases of larynx
478.8–478.9	Other diseases of larynx, not else where classified
480.0–480.3	Viral pneumonia
480.8–480.9	Viral pneumonia
481	Pneumococcal pneumonia [streptococcus pneumoniae pneumonia]
482.1	Pneumonia due to pseudomonas
482.30–482.32	Pneumonia due to streptococcus
482.39	Pneumonia due to other streptococcus
482.40–482.42	Pneumonia due to staphylococcus unspecified
482.49	Other staphylococcus pneumonia
482.81–482.84	Pneumonia due to other specified bacteria
482.89	Pneumonia due to other specified bacteria
483.0–483.1	Pneumonia due to other specified organism
483.8	Pneumonia due to other specified organism
484.1	Pneumonia in cytomegalic inclusion disease
484.3	Pneumonia in whooping cough
484.5–484.8	Pneumonia in infectious diseases classified elsewhere
485	Bronchopneumonia organism unspecified
486	Pneumonia organism unspecified
487.0–487.1	Influenza
490	Bronchitis not specified as acute or chronic
491.1	Mucopurulent chronic bronchitis
491.20–491.21	Obstructive chronic bronchitis
492.0	Emphysematous bleb
492.8	Other emphysema
493.00–493.02	Extrinsic asthma
493.10–493.12	Intrinsic asthma
493.20–493.22	Chronic obstructive
493.81–493.82	Other forms of asthma
493.90–493.92	Asthma unspecified
494.0–494.1	Bronchiectasis
495.0–495.9	Extrinsic allergic alveolitis
496	Chronic airway obstruction not elsewhere classified
500	Coal workers' pneumoconiosis
501	Asbestosis
502	Pneumoconiosis due to other silica or silicates
503	Pneumoconiosis due to other inorganic dust
504	Pneumonopathy due to inhalation of other dust
505	Pneumoconiosis unspecified
506.0–506.4	Respiratory conditions due to chemical fumes and vapors
506.9	Unspecified respiratory conditions due to fumes and vapors
507.0–507.1	Pneumonitis due to solids and liquids
507.8	Pneumonitis due to other solids and liquids
508.0–508.1	Respiratory conditions due to other and unspecified external agents
508.8–508.9	Respiratory conditions due to other and unspecified external agents
510.0	Empyema with fistula
510.9	Empyema without fistula
511.0–511.1	Pleurisy
511.81	Malignant pleural effusion
511.89	Other specified forms of effusion, except tuberculous
511.9	Unspecified pleural effusion
512.0–512.1	Pneumothorax
512.8	Other spontaneous pneumothorax
513.0–513.1	Abscess of lung and mediastinum
514	Pulmonary congestion and hypostasis
515	Postinflammatory pulmonary fibrosis
516.0–516.3	Other alveolar and parietoalveolar pneumonopathies
516.8–516.9	Other alveolar and parietoalveolar pneumonopathies
517.1–517.3	Lung involvement in conditions classified elsewhere
517.8	Lung involvement in other diseases classified elsewhere
518.0–518.7	Other diseases of lung
518.81–518.84	Other diseases of lung
518.89	Other diseases of lung not elsewhere classified
519.11	Acute bronchospasm
519.19	Other diseases of trachea and bronchus
519.4	Disorders of diaphragm
710.1	Systemic sclerosis
780.2	Syncope and collapse
780.31–780.33	Convulsions
780.39	Other convulsions
780.79	Other malaise and fatigue
782.5	Cyanosis
785.50–785.52	Shock without mention of trauma
785.59	Other shock without trauma
786.00–786.07	Dyspnea and respiratory abnormalities
786.09	Respiratory abnormality other
786.1	Stridor
786.30	Hemoptysis, unspecified
786.39	Other hemoptysis
786.50–786.52	Chest pain
786.59	Other chest pain
793.1–793.2	Nonspecific abnormal findings on radiological and other examinations of body structure
799.01–799.02	Asphyxia and hypoxemia
799.82	Apparent life threatening event in infant
805.00–805.08	Closed fracture of cervical vertebra unspecified level
805.10–805.18	Open fracture of cervical vertebra unspecified level
805.2–805.7	Fracture of vertebral column without mention of spinal cord injury
806.00–806.09	Cervical closed (fracture of vertebral column with spinal cord injury)
806.10–806.19	Cervical open (fracture of vertebral column with spinal cord injury )
806.20–806.29	Dorsal (thoracic) closed (fracture of vertebral column with spinal cord injury)
806.30–806.39	Dorsal (thoracic) open (fracture of vertebral column with spinal cord injury)
806.4–806.5	Fracture of vertebral column without mention of spinal cord injury
806.60–806.62	Sacrum and coccyx closed (fracture of vertebral column with spinal cord injury)
806.69	Closed fracture of sacrum and coccyx with other spinal cord injury
806.70–806.72	Sacrum and coccyx open (fracture of vertebral column with spinal cord injury)
806.79	Open fracture of sacrum and coccyx with other spinal cord injury
807.00–807.09	Rib(s) closed (fracture of rib(s), sternum, and treachea)
807.10–807.19	Rib(s) open (fracture of rib(s), sternum, and treachea)
807.2–807.6	Fracture of rib(s), sternum, and treachea
854.00–854.06	Intracranial injury of other and unspecified nature
854.09	Intracranial injury of other and unspecified nature
854.10–854.16	Intracranial injury of other and unspecified nature
854.19	Intracranial injury of other and unspecified
860.0–860.5	Traumatic pneumothorax and hemothorax
861.00–861.03	Heart without mention of open wound into thorax
861.10–861.13	Heart with open wound into thorax
861.20–861.22	Lung without mention of open wound into thorax
861.30–861.32	Lung with open wound into thorax
862.0–862.1	Injury to other and unspecified intrathoracic organs
862.21–862.22	Other specified intrathoracic organs, without mention of open wound into cavity
862.29	Injury to other specified intrathoracic organs without open wound into cavity
862.31–862.32	Other specified intrathoracic organs, with open wound into cavity
862.39	Injury to other specified intrathoracic organs with open wound into cavity
862.8–862.9	Injury to other and unspecified intrathoracic organs
863.1	Injury to stomach with open wound into cavity
863.20–863.21	Small intrestine without mention of open wound into cavity
863.29	Other injury to small intestine without open wound into cavity
863.30–863.31	Small intestine with open wound into cavity
863.39	Other injury to small intestine with open wound into cavity
863.40–863.46	Colon or rectum without mention of open wound into cavity
863.49	Other injury to colon and rectum without open wound into cavity
863.50–863.56	Colon or rectum with open wound into cavity
863.59	Other injury to colon and rectum with open wound into cavity
863.80–863.85	Other and unspecified gastrointestinal sites without mention of open wound into cavity
863.89	Injury to other and unspecified gastrointestinal sites without open wound into cavity
863.90–863.95	Other and unspecified gastrointestinal sites with open wound into cavity
863.99	Injury to other and unspecified gastrointestinal sites with open wound into cavity
864.00–864.05	Injury to liver (without mention of open wound into cavity)
864.09	Other injury to liver without open wound into cavity
864.10–864.15	Injury to liver (with open wound into cavity)
864.19	Other injury to liver with open wound into cavity
865.00–865.04	Injury to spleen (without mention of open wound into cavity)
865.09	Other injury into spleen without open wound into cavity
865.10–865.14	Injury to spleen (with open wound into cavity)
865.19	Other injury to spleen with open wound into cavity
866.00–866.03	Injury to kidney without mention of open wound into cavity
866.10–866.13	Injury to kidney with open wound into cavity
867.0–867.9	Injury to pelvic organs
868.00–868.04	Injury to unspecified intra-abdominal organs
868.09	Injury to other and multiple intra-abdominal organs without open wound into cavity
868.10–868.14	Injury to other intra-abdominal organs without mention of open wound into cavity
868.19	Injury to other and multiple intra-abdominal organs with open wound into cavity
869.0–869.1	Internal injury to unspecified or ill-defined organs
933.1	Foreign body in larynx
934.0–934.1	Foreign body in trachea, bronchus and lung
934.8–934.9	Foreign body in trachea, bronchus and lung
941.20–941.29	Blisters with epidermal loss due to burn (second degree)
941.30–941.39	Full-thickness skin loss due to burn (third degree NOS)
941.40–941.49	Deep necrosis of underlying tissues due to burn (deep third degree) without mention of a body part
941.50–941.59	Deep necrosis of underlying tissues (deep third degree) with loss of body part
942.20–942.25	Blisters with epidermal loss (second degree)
942.29	Blisters with epidermal loss (second degree) other and multiple sites of trunk
942.30–942.35	Full-thickness skin loss (third degree NOS)
942.39	Full-thickness skin loss (third degree NOS) other and multiple sites of trunk
942.40–942.45	Deep necrosis of underlying tissues (deep third degree) without mention of loss of body part
942.49	Deep necrosis of underlying tissues (deep third degree) other and multiple sites of trunk
942.50–942.55	Deep necrosis of underlying tissues (deep third degree) with loss of body part
942.59	Deep necrosis of underlying tissues (deep third degree) other and multiple sites of trunk
943.20–943.26	Blisters with epidermal loss (second degree)
943.29	Blisters with epidermal loss (second degree) of multiple sites of upper limb except wrist and hand
943.30–943.36	Full-thickness skin loss (third degree NOS)
943.39	Full-thickness skin loss due to burn (third degree nos) of multiple sites of upper limb except wrist and hand
943.40–943.46	Deep necrosis of underlying tissues due to burn (deep third degree) without mention of loss of a body part
943.49	Deep necrosis of underlying tissues due to burn (deep third degree) of multiple sites of upper limb except wrist and hand without loss of upper limb
943.50–943.56	Deep necrosis of underlying tissues due to burn (deep third degree) with loss of a body part
943.59	Deep necrosis of underlying tissues due to burn (deep third degree) of multiple sites of upper limb except wrist and hand with loss of upper limb
944.20–944.28	Blisters with epidermal loss due to burn (second degree) – wrist(s) and hand(s)
944.30–944.38	Full-thickness skin loss due to burn (third degree nos) – wrist(s) and hand(s)
944.40–944.48	Deep necrosis of underlying tissues due to burn (deep third degree) without loss of a wrist(s) and hand(s)
944.50–944.58	Deep necrosis of underlying tissues due to burn (deep third degree) with loss of wrist(s) and hand(s)
945.20–945.26	Blisters epidermal loss (second degree) of lower limb (leg)
945.29	Blisters with epidermal loss due to burn (second degree) of multiple sites of lower limb(s)
945.30–945.36	Full-thickness skin loss due to burn (third degree nos) of lower limb
945.39	Full-thickness skin loss due to burn (third degree nos) of multiple sites of lower limb(s)
945.40–945.46	Deep necrosis of underlying tissues due to burn (deep third degree) without mention of loss of lower limb (leg)
945.49	Deep necrosis of underlying tissues due to burn (deep third degree) of multiple sites of lower limb(s) without loss of a body part
945.50–945.56	Deep necrosis of underlying tissues due to burn (deep third degree) with loss of lower limb (leg)
945.59	Deep necrosis of underlying tissues due to burn (deep third degree) of multiple sites of lower limb(s) with loss of a body part
946.2–946.5	Burns of multiple sites
947.0–947.4	Burn of internal organs
948.00	Burn (any degree) involving less than 10 percent of body surface
948.10–948.11	10–19 percent of body surface
948.20–948.22	20–29 percent of body surface
948.30–948.33	30–39 percent of body surface
948.40–948.44	40–49 percent of body surface
948.50–948.55	50–59 percent of body surface
948.60–948.66	60–69 percent of body surface
948.70–948.77	70–79 percent of body surface
948.80–948.88	80–89 percent of body surface
948.90–948.99	90 percent or more of body surface
949.2–949.5	Burn unspecified
959.8	Other and unspecified injury to other specified sites including multiple
960.0–960.9	Poisoning by antibiotics
961.0–961.9	Poisoning by other anti-infectives
962.0–962.9	Poisoning by hormones and synthetic substitutes
963.0–963.5	Poisoning by primarily systemic drugs
963.8–963.9	Poisoning by primarily systemic agents
964.0–964.9	Poisoning by agents primarily affecting blood constituents
965.00–965.02	Poisoning by opium (alkaloids) and related narcotics
965.09	Poisoning by other opiates and related narcotics
965.1	Poisoning by salicylates
965.4–965.5	Poisoning by analgesics, antipyretics and antirheumatics
965.61	Poisoning by propionic acid derivatives
965.69	Poisoning by other antirheumatics
965.7–965.9	Poisoning by analgesics, antipyretics and antirheumatics
966.0–966.4	Poisoning by anticonvulsants and anti-Parkinsonism drugs
967.0–967.6	Poisoning by sedatives and hypnotics
967.8–967.9	Poisoning by sedatives and hypnotics
968.0–968.7	Poisoning by other central nervous system depressants and anesthetics
968.9	Poisoning by other and unspecified local anesthetics
969.00–969.05	Poisoning by antidepressants
969.09	Poisoning by other antidepressants
969.1–969.6	Poisoning by psychotropic agents
969.70–969.73	Poisoning by psychostimulants
969.79	Poisoning by other psychostimulants
969.8–969.9	Poisoning by psychotropic agents
970.0–970.1	Poisoning by central nervous system stimulants
970.81	Poisoning by cocaine
970.89	Poisoning by other central nervous system stimulants
970.9	Unspecified central nervous system stimulant
971.0–971.3	Poisoning by drugs primarily affecting autonomic nervous system
971.9	Poisoning by unspecified drug primarily affecting autonomic nervous system
972.0–972.9	Poisoning by agents primarily affecting the cardiovascular system
973.0–973.9	Poisoning by agents primarily affecting the gastrointestinal system
974.0–974.7	Poisoning by water, mineral and uric acid metabolism drugs
975.0–975.8	Poisoning by agents primarily acting on the smooth and skeletal muscles and respiratory system
976.0–976.9	Poisoning by agents primarily affecting skin and mucous membrane
977.0–977.4	Poisoning by other and unspecified drugs and medicinal substances
977.8–977.9	Poisoning by other and unspecified drugs and medicinal substances
978.0–978.6	Poisoning by bacterial vaccines
978.8–978.9	Poisoning by bacterial vaccines
979.0–979.7	Poisoning by other vaccines and biological substances
979.9	Poisoning by other and unspecified vaccines and biological substances
980.0–980.3	Toxic effect of alcohol
980.8–980.9	Toxic effect of alcohol
981	Toxic effect of petroleum products
982.0–982.4	Toxic effect of solvents other than petroleum-based
982.8	Toxic effect of other nonpetroleum-based solvents
983.0–983.2	Toxic effect of corrosive aromatics, acids and caustic alkalis
983.9	Toxic effect of caustic unspecified
984.0–984.1	Toxic effect of lead and its compounds (including fumes)
984.8–984.9	Toxic effect of lead and its compounds (including fumes)
985.0–985.6	Toxic effect of other metals
985.8–985.9	Toxic effect of other metals
986	Toxic effect of carbon monoxide
987.0–987.9	Toxic effect of other gases, fumes or vapors
988.0–988.2	Toxic effect of noxious substances eaten as food
988.8–988.9	Toxic effect of noxious substances eaten as food
989.0–989.7	Toxic effect of other substances, chiefly nonmedical as to
989.81–989.84	Toxic effect of asbestos
989.89	Other substances chiefly nonmedicinal as to source
994.1	Drowning and nonfatal submersion
994.7	Asphyxiation and strangulation
997.31	Ventilator associated pneumonia
997.39	Other respiratory complications
V42.6	Lung replaced by transplant
V58.69	Long-term (current) use of other medications
V67.2	Follow-up examination following chemotherapy
V67.51	Follow-up examination following completed treatment with high-risk medication not elsewhere classified

Medicare is establishing the following limited coverage for CPT/HCPCS code 94762:

Covered for:

327.21*–327.27*	Organic sleep apnea
415.12	Septic pulmonary embolism
416.0	Primary pulmonary hypertension
416.2	Chronic pulmonary embolism
416.8*–416.9*	Chronic pulmonary heart disease
428.0*–428.1*	Heart failure
428.20*–428.23*	Systolic heart failure
428.30*–428.33*	Diastolic heart failure
428.40*–428.43*	Combined systolic and diastolic heart failure
428.9*	Heart failure unspecified
492.8*	Other emphysema
496*	Chronic airway obstruction not elsewhere classified
780.09	Alteration of consciousness other
780.51	Insomnia with sleep apnea, unspecified
780.53	Hypersomnia with sleep apnea, unspecified
780.54*	Hypersomnia, unspecified
780.57	Unspecified sleep apnea
799.01*	Asphyxia
799.02*	Hypoxemia
799.82	Apparent life threatening event in infant
V12.53	Personal history of sudden cardiac arrest
	Note: * These codes are to be used only for those patients who exhibit signs and symptoms of oxygen deprivation (supported by the patient’s medical record).

Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Documentation Requirements

Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.

Information in the patient’s record must support the medical necessity of the procedure.

Continuous overnight monitoring in the home (94762) is covered only when the results are reliable in that setting. The patient’s record must document that the oximeter is present and self-sealed and cannot be adjusted by the patient. In addition, the device must provide a printout that documents an adequate number of sampling hours (a minimum of four hours should be recorded), percent of oxygen saturation and an aggregate of the results. This information must be available if requested.

Part B: Office or home health care records or certification of medical necessity should clearly document the reason for the testing, its frequency and the results. An appropriate history and physical exam and progress notes must also be available for review.

When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.

When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request.

Utilization Guidelines

In outpatient or home management for patients with chronic cardiopulmonary problems, oximetric determinations once or twice a year are considered reasonable. In all instances, there must be a documented request by a physician/non-physician provider in the medical record for these services. Regular or routine testing will not be allowed for reimbursement. In all circumstances, testing would be expected to be useful in the continued management of a patient, particularly in acute exacerbations or unstable conditions (e.g., acute bronchitis in a patient with Chronic Obstructive Pulmonary Disease (COPD)) where increased frequency of testing would be considered, on an individual consideration basis, for coverage purposes.

Only one service (oximetry determination) per day will be allowed for testing at a reasonable frequency and if medically necessary regardless of whether the patient is sitting, standing or lying, with or without exercise or oxygen use, unless medical necessity can be demonstrated for additional needs on an individual consideration basis.

More frequent testing may be allowed, on an individual consideration basis, when there is documentation of an acute exacerbation of a chronic pulmonary disease or other acute illnesses with signs indicating or suggesting increased hypoxemia.

Notice: This LCD imposes utilization guideline limitations. Despite Medicare’s allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services.