LCD/NCD Portal

L29236 NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION

 

 

10/01/2011

 

 

Indications and Limitations of Coverage and/or Medical Necessity

 

• Single and Multiple Determinations (94760, 94761):

o Medicare will consider ear or pulse oximetry for oxygen saturation (CPT Codes 94760, 94761) to be 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-9 Codes That Support Medical Necessity).

• Continuous Overnight Monitoring (94762):

o Medicare will consider ear or pulse oximetry for oxygen saturation by continuous overnight monitoring (CPT code 94762) to be medically necessary in the following circumstances (see ICD-9 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.

 

 

CPT/HCPCS Codes

 

94760 NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; SINGLE DETERMINATION

94761 NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; MULTIPLE DETERMINATIONS (EG, DURING EXERCISE)

94762 NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; BY CONTINUOUS OVERNIGHT MONITORING (SEPARATE PROCEDURE)

 

 

ICD-9 Codes that Support Medical Necessity

 

Single and Multiple Determinations (94760, 94761):

 

162.2 MALIGNANT NEOPLASM OF MAIN BRONCHUS

162.3 MALIGNANT NEOPLASM OF UPPER LOBE BRONCHUS OR LUNG

162.4 MALIGNANT NEOPLASM OF MIDDLE LOBE BRONCHUS OR LUNG

162.5 MALIGNANT NEOPLASM OF LOWER LOBE BRONCHUS OR LUNG

162.8 MALIGNANT NEOPLASM OF OTHER PARTS OF BRONCHUS OR LUNG

162.9 MALIGNANT NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED

391.8 OTHER ACUTE RHEUMATIC HEART DISEASE

398.91 RHEUMATIC HEART FAILURE (CONGESTIVE)

402.01 MALIGNANT HYPERTENSIVE HEART DISEASE WITH HEART FAILURE

402.11 BENIGN HYPERTENSIVE HEART DISEASE WITH HEART FAILURE

402.91 UNSPECIFIED HYPERTENSIVE HEART DISEASE WITH HEART FAILURE

404.01 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED

404.03 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

404.11 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED

404.13 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

404.91 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED

404.93 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

428.0 CONGESTIVE HEART FAILURE UNSPECIFIED

428.1 LEFT HEART FAILURE

428.20 UNSPECIFIED SYSTOLIC HEART FAILURE

428.21 ACUTE SYSTOLIC HEART FAILURE

428.22 CHRONIC SYSTOLIC HEART FAILURE

428.23 ACUTE ON CHRONIC SYSTOLIC HEART FAILURE

428.30 UNSPECIFIED DIASTOLIC HEART FAILURE

428.31 ACUTE DIASTOLIC HEART FAILURE

428.32 CHRONIC DIASTOLIC HEART FAILURE

428.33 ACUTE ON CHRONIC DIASTOLIC HEART FAILURE

428.40 UNSPECIFIED COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE

428.41 ACUTE COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE

428.42 CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE

428.43 ACUTE ON CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE

428.9 HEART FAILURE UNSPECIFIED

491.20 OBSTRUCTIVE CHRONIC BRONCHITIS WITHOUT EXACERBATION

491.21 OBSTRUCTIVE CHRONIC BRONCHITIS WITH (ACUTE) EXACERBATION

492.0 EMPHYSEMATOUS BLEB

492.8 OTHER EMPHYSEMA

493.00 EXTRINSIC ASTHMA UNSPECIFIED

493.01 EXTRINSIC ASTHMA WITH STATUS ASTHMATICUS

493.02 EXTRINSIC ASTHMA WITH (ACUTE) EXACERBATION

493.10 INTRINSIC ASTHMA UNSPECIFIED

493.11 INTRINSIC ASTHMA WITH STATUS ASTHMATICUS

493.12 INTRINSIC ASTHMA WITH (ACUTE) EXACERBATION

493.20 CHRONIC OBSTRUCTIVE ASTHMA UNSPECIFIED

493.21 CHRONIC OBSTRUCTIVE ASTHMA WITH STATUS ASTHMATICUS

493.22 CHRONIC OBSTRUCTIVE ASTHMA WITH (ACUTE) EXACERBATION

493.81 EXERCISE-INDUCED BRONCHOSPASM

493.82 COUGH VARIANT ASTHMA

493.90 ASTHMA UNSPECIFIED

493.91 ASTHMA UNSPECIFIED TYPE WITH STATUS ASTHMATICUS

493.92 ASTHMA UNSPECIFIED WITH (ACUTE) EXACERBATION

494.0 BRONCHIECTASIS WITHOUT ACUTE EXACERBATION

494.1 BRONCHIECTASIS WITH ACUTE EXACERBATION

496 CHRONIC AIRWAY OBSTRUCTION NOT ELSEWHERE CLASSIFIED

515 POSTINFLAMMATORY PULMONARY FIBROSIS

518.51 ACUTE RESPIRATORY FAILURE FOLLOWING TRAUMA AND SURGERY

518.52 OTHER PULMONARY INSUFFICIENCY, NOT ELSEWHERE CLASSIFIED, FOLLOWING TRAUMA AND SURGERY

518.53 ACUTE AND CHRONIC RESPIRATORY FAILURE FOLLOWING TRAUMA AND SURGERY

518.81 ACUTE RESPIRATORY FAILURE

518.82 OTHER PULMONARY INSUFFICIENCY NOT ELSEWHERE CLASSIFIED

518.83 CHRONIC RESPIRATORY FAILURE

518.84 ACUTE AND CHRONIC RESPIRATORY FAILURE

518.89 OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED

786.03 APNEA

786.04 CHEYNE-STOKES RESPIRATION

786.05 SHORTNESS OF BREATH

786.06 TACHYPNEA

786.07 WHEEZING

786.09 RESPIRATORY ABNORMALITY OTHER

 

 

Continuous Overnight Monitoring (94762):

 

162.2 MALIGNANT NEOPLASM OF MAIN BRONCHUS

162.3 MALIGNANT NEOPLASM OF UPPER LOBE BRONCHUS OR LUNG

162.4 MALIGNANT NEOPLASM OF MIDDLE LOBE BRONCHUS OR LUNG

162.5 MALIGNANT NEOPLASM OF LOWER LOBE BRONCHUS OR LUNG

162.8 MALIGNANT NEOPLASM OF OTHER PARTS OF BRONCHUS OR LUNG

162.9 MALIGNANT NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED

391.8 OTHER ACUTE RHEUMATIC HEART DISEASE

398.91 RHEUMATIC HEART FAILURE (CONGESTIVE)

402.01 MALIGNANT HYPERTENSIVE HEART DISEASE WITH HEART FAILURE

402.11 BENIGN HYPERTENSIVE HEART DISEASE WITH HEART FAILURE

402.91 UNSPECIFIED HYPERTENSIVE HEART DISEASE WITH HEART FAILURE

404.01 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED

404.03 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

404.11 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED

404.13 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

404.91 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED

404.93 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

428.0 CONGESTIVE HEART FAILURE UNSPECIFIED

428.1 LEFT HEART FAILURE

428.20 UNSPECIFIED SYSTOLIC HEART FAILURE

428.21 ACUTE SYSTOLIC HEART FAILURE

428.22 CHRONIC SYSTOLIC HEART FAILURE

428.23 ACUTE ON CHRONIC SYSTOLIC HEART FAILURE

428.30 UNSPECIFIED DIASTOLIC HEART FAILURE

428.31 ACUTE DIASTOLIC HEART FAILURE

428.32 CHRONIC DIASTOLIC HEART FAILURE

428.33 ACUTE ON CHRONIC DIASTOLIC HEART FAILURE

428.40 UNSPECIFIED COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE

428.41 ACUTE COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE

428.42 CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE

428.43 ACUTE ON CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE

428.9 HEART FAILURE UNSPECIFIED

491.20 OBSTRUCTIVE CHRONIC BRONCHITIS WITHOUT EXACERBATION

491.21 OBSTRUCTIVE CHRONIC BRONCHITIS WITH (ACUTE) EXACERBATION

492.0 EMPHYSEMATOUS BLEB

492.8 OTHER EMPHYSEMA

493.00 EXTRINSIC ASTHMA UNSPECIFIED

493.01 EXTRINSIC ASTHMA WITH STATUS ASTHMATICUS

493.02 EXTRINSIC ASTHMA WITH (ACUTE) EXACERBATION

493.10 INTRINSIC ASTHMA UNSPECIFIED

493.11 INTRINSIC ASTHMA WITH STATUS ASTHMATICUS

493.12 INTRINSIC ASTHMA WITH (ACUTE) EXACERBATION

493.20 CHRONIC OBSTRUCTIVE ASTHMA UNSPECIFIED

493.21 CHRONIC OBSTRUCTIVE ASTHMA WITH STATUS ASTHMATICUS

493.22 CHRONIC OBSTRUCTIVE ASTHMA WITH (ACUTE) EXACERBATION

493.81 EXERCISE-INDUCED BRONCHOSPASM

493.82 COUGH VARIANT ASTHMA

493.90 ASTHMA UNSPECIFIED

493.91 ASTHMA UNSPECIFIED TYPE WITH STATUS ASTHMATICUS

493.92 ASTHMA UNSPECIFIED WITH (ACUTE) EXACERBATION

494.0 BRONCHIECTASIS WITHOUT ACUTE EXACERBATION

494.1 BRONCHIECTASIS WITH ACUTE EXACERBATION

496 CHRONIC AIRWAY OBSTRUCTION NOT ELSEWHERE CLASSIFIED

515 POSTINFLAMMATORY PULMONARY FIBROSIS

518.51 ACUTE RESPIRATORY FAILURE FOLLOWING TRAUMA AND SURGERY

518.52 OTHER PULMONARY INSUFFICIENCY, NOT ELSEWHERE CLASSIFIED, FOLLOWING TRAUMA AND SURGERY

518.53 ACUTE AND CHRONIC RESPIRATORY FAILURE FOLLOWING TRAUMA AND SURGERY

518.81 ACUTE RESPIRATORY FAILURE

518.82 OTHER PULMONARY INSUFFICIENCY NOT ELSEWHERE CLASSIFIED

518.83 CHRONIC RESPIRATORY FAILURE

518.84 ACUTE AND CHRONIC RESPIRATORY FAILURE

518.89 OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED

780.51 INSOMNIA WITH SLEEP APNEA, UNSPECIFIED

780.53 HYPERSOMNIA WITH SLEEP APNEA, UNSPECIFIED

780.57 UNSPECIFIED SLEEP APNEA

786.03 APNEA

786.04 CHEYNE-STOKES RESPIRATION

786.05 SHORTNESS OF BREATH

786.06 TACHYPNEA

786.07 WHEEZING

786.09 RESPIRATORY ABNORMALITY OTHER

 

 

Documentation Requirements

 

• Medical record documentation maintained by the ordering/referring physician (e.g., office/progress notes) must indicate the medical necessity for performing ear or pulse oximetry studies.

o Additionally, a copy of the study results should be maintained in the medical records.

• If the provider of oximetry studies is other than the ordering/referring physician, that provider must maintain hard copy documentation of test results and interpretation along with copies of the ordering/referring physician's order for the study.

o The ordering/referring physician must state the clinical indication/medical necessity for the oximetry study in the order for the test.

 

 

Treatment Logic

 

• 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 nail bed 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 nail bed.

• Ear oximetry is a noninvasive method for evaluating arterial oxygenation.

• Ear oximeters are commonly used in sleep studies.

 

 

Sources of Information and Basis for Decision

 

10/01/2011

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

 

AMA CPT / ADA CDT Copyright Statement

 

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

CMS LCD NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION