L29236-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Noninvasive Ear or Pulse Oximetry

For Oxygen Saturation (L29236)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29236

LCD Title Noninvasive Ear or Pulse Oximetry For Oxygen Saturation

Contractor's Determination Number 94760

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/02/2009 Original Determination Ending Date

Revision Effective Date

For services performed on or after 10/01/2011 Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See § 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: Medicare Benefit Policy Manual, Chapter 15, section 80

Indications and Limitations of Coverage 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):

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):

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.

Coding Information

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.

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.

99999 Not Applicable

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 - 162.9 MALIGNANT NEOPLASM OF MAIN BRONCHUS - 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 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART

404.01 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 - 428.9 CONGESTIVE HEART FAILURE UNSPECIFIED - HEART FAILURE UNSPECIFIED

491.20 - 491.21 OBSTRUCTIVE CHRONIC BRONCHITIS WITHOUT EXACERBATION - OBSTRUCTIVE CHRONIC BRONCHITIS WITH (ACUTE) EXACERBATION

492.0 - 492.8 EMPHYSEMATOUS BLEB - OTHER EMPHYSEMA

493.00 - 493.92 EXTRINSIC ASTHMA UNSPECIFIED - ASTHMA UNSPECIFIED WITH (ACUTE) EXACERBATION

494.0 - 494.1 BRONCHIECTASIS WITHOUT ACUTE EXACERBATION - BRONCHIECTASIS WITH ACUTE EXACERBATION

496 CHRONIC AIRWAY OBSTRUCTION NOT ELSEWHERE CLASSIFIED

515 POSTINFLAMMATORY PULMONARY FIBROSIS

518.51 - 518.53 ACUTE RESPIRATORY FAILURE FOLLOWING TRAUMA AND SURGERY - ACUTE AND CHRONIC RESPIRATORY FAILURE FOLLOWING TRAUMA AND SURGERY

518.81 - 518.89 ACUTE RESPIRATORY FAILURE - OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED

786.3 APNEA

786.4 CHEYNE-STOKES RESPIRATION

786.5 SHORTNESS OF BREATH

786.6 TACHYPNEA

786.7 WHEEZING

786.09 RESPIRATORY ABNORMALITY OTHER

Continuous Overnight Monitoring (94762):

162.2 - 162.9 MALIGNANT NEOPLASM OF MAIN BRONCHUS - 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 - 428.9 CONGESTIVE HEART FAILURE UNSPECIFIED - HEART FAILURE UNSPECIFIED

491.20 - 491.21 OBSTRUCTIVE CHRONIC BRONCHITIS WITHOUT EXACERBATION - OBSTRUCTIVE CHRONIC BRONCHITIS WITH (ACUTE) EXACERBATION

492.0 - 492.8 EMPHYSEMATOUS BLEB - OTHER EMPHYSEMA

493.00 - 493.92 EXTRINSIC ASTHMA UNSPECIFIED - ASTHMA UNSPECIFIED WITH (ACUTE) EXACERBATION

494.0 - 494.1 BRONCHIECTASIS WITHOUT ACUTE EXACERBATION - BRONCHIECTASIS WITH ACUTE EXACERBATION

496 CHRONIC AIRWAY OBSTRUCTION NOT ELSEWHERE CLASSIFIED

515 POSTINFLAMMATORY PULMONARY FIBROSIS

518.51 - 518.53 ACUTE RESPIRATORY FAILURE FOLLOWING TRAUMA AND SURGERY - ACUTE AND CHRONIC RESPIRATORY FAILURE FOLLOWING TRAUMA AND SURGERY

518.81 - 518.89 ACUTE RESPIRATORY FAILURE - 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

786.3 APNEA

786.4 CHEYNE-STOKES RESPIRATION

786.5 SHORTNESS OF BREATH

786.6 TACHYPNEA

786.7 WHEEZING

786.09 RESPIRATORY ABNORMALITY OTHER

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations 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. 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. The ordering/referring physician must state the clinical indication/medical necessity for the

oximetry study in the order for the test.

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they

may be subject to review for medical necessity.

Sources of Information and Basis for Decision

N/A Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was developed in cooperation with advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 12/04/2008

Revision History Number 1

Revision History Explanation Revision Number:1 Start Date of Comment Period:N/A

Start Date of Notice Period:10/01/2011 Revised Effective Date: 10/01/2011

LCR B2011-101

September 2011 Connection

Explanation of Revision: Annual 2012 ICD-9-CM Update. Deleted diagnosis code 518.5 and replaced it with diagnosis code range 518.51-518.53 for CPT codes 94760, 94761 and 94762. The effective date of this revision is based on date of service.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29236) replaces LCD L5990 as the policy in notice. This document (L29236) is effective on 02/02/2009.

08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.

Reason for Change