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Local Coverage Determination (LCD)

Oximetry Services

L35434

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
Novitas Solutions, Inc.	A and B MAC	04111 - MAC A	J - H	Colorado
Novitas Solutions, Inc.	A and B MAC	04112 - MAC B	J - H	Colorado
Novitas Solutions, Inc.	A and B MAC	04211 - MAC A	J - H	New Mexico
Novitas Solutions, Inc.	A and B MAC	04212 - MAC B	J - H	New Mexico
Novitas Solutions, Inc.	A and B MAC	04311 - MAC A	J - H	Oklahoma
Novitas Solutions, Inc.	A and B MAC	04312 - MAC B	J - H	Oklahoma
Novitas Solutions, Inc.	A and B MAC	04411 - MAC A	J - H	Texas
Novitas Solutions, Inc.	A and B MAC	04412 - MAC B	J - H	Texas
Novitas Solutions, Inc.	A and B MAC	04911 - MAC A	J - H	Colorado New Mexico Oklahoma Texas
Novitas Solutions, Inc.	A and B MAC	07101 - MAC A	J - H	Arkansas
Novitas Solutions, Inc.	A and B MAC	07102 - MAC B	J - H	Arkansas
Novitas Solutions, Inc.	A and B MAC	07201 - MAC A	J - H	Louisiana
Novitas Solutions, Inc.	A and B MAC	07202 - MAC B	J - H	Louisiana
Novitas Solutions, Inc.	A and B MAC	07301 - MAC A	J - H	Mississippi
Novitas Solutions, Inc.	A and B MAC	07302 - MAC B	J - H	Mississippi
Novitas Solutions, Inc.	A and B MAC	12101 - MAC A	J - L	Delaware
Novitas Solutions, Inc.	A and B MAC	12102 - MAC B	J - L	Delaware
Novitas Solutions, Inc.	A and B MAC	12201 - MAC A	J - L	District of Columbia
Novitas Solutions, Inc.	A and B MAC	12202 - MAC B	J - L	District of Columbia
Novitas Solutions, Inc.	A and B MAC	12301 - MAC A	J - L	Maryland
Novitas Solutions, Inc.	A and B MAC	12302 - MAC B	J - L	Maryland
Novitas Solutions, Inc.	A and B MAC	12401 - MAC A	J - L	New Jersey
Novitas Solutions, Inc.	A and B MAC	12402 - MAC B	J - L	New Jersey
Novitas Solutions, Inc.	A and B MAC	12501 - MAC A	J - L	Pennsylvania
Novitas Solutions, Inc.	A and B MAC	12502 - MAC B	J - L	Pennsylvania
Novitas Solutions, Inc.	A and B MAC	12901 - MAC A	J - L	Delaware District of Columbia Maryland New Jersey Pennsylvania

LCD Information

Document Information

LCD ID
L35434

LCD Title
Oximetry Services

Proposed LCD in Comment Period
N/A

Source Proposed LCD
N/A

Original Effective Date
For services performed on or after 10/01/2015

Revision Effective Date
For services performed on or after 10/17/2019

Revision Ending Date
N/A

Retirement Date
N/A

Notice Period Start Date
N/A

Notice Period End Date
N/A

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Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for oximetry services. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for oximetry services and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site:

IOM Citations:

CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 60 Services and Supplies
CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 240.2 Home Use of Oxygen
CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4, Reasonable and Necessary Provision in an LCD

Social Security Act (Title XVIII) Standard References:

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.
Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Notice: Compliance with the provisions in this policy may be monitored and addressed through post-payment data analysis and subsequent medical review audits.

History/Background and/or General Information

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.

Covered Indications

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

Overnight Oximetry 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

Limitations

The following are considered not reasonable and necessary:

Routine use of oximetry
Results of tests performed by a durable medical equipment supplier to qualify patients for home oxygen service

Place of Services (POS)

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

For additional information on services performed in an Independent Diagnostic Testing Facility (IDTF), please refer to Local Coverage Determination (LCD) L35448 Independent Diagnostic Testing Facility (IDTF) and Local Coverage Article: Billing and Coding: Independent Diagnostic Testing Facility (IDTF) A53252.

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.

For frequency limitations please refer to the Utilization Guidelines section below.

Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes

Changes	Fields Changed
	N/A

Associated Information

Sources of Information

Bibliography

Open Meetings

Contractor Advisory Committee (CAC) Meetings

MAC Meeting Information URLs

Proposed LCD Posting Date

Comment Period Start Date

Comment Period End Date

Reason for Proposed LCD

Requestor Name	Requestor Letter
	View Letter

Requestor Information

Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code	Description
Please accept the License to see the codes.

Revenue Codes

Code	Description
Please accept the License to see the codes.

ICD-10-CM Codes that Support Medical Necessity

ICD-10-CM Codes that DO NOT Support Medical Necessity

Additional ICD-10 Information

General Information

Associated Information

Refer to the Local Coverage Article: Billing and Coding: Oximetry Services, A57205 for all coding information.

Documentation Requirements

All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
The medical record documentation must support the medical necessity of the services as stated in this policy.
Continuous overnight monitoring in the home 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.

Utilization Guidelines

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

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.

Sources of Information

L32700, Oximetry Services, Novitas Solutions Jurisdiction H Local Coverage Determination

Other Contractor Policies

Contractor Medical Directors

Bibliography

N/A

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation	Reasons for Change
10/17/2019	R5	LCD revised and published on 10/17/2019. Consistent with CMS CR 10901 all coding instructions and code sections have been removed from the policy and placed in the related Billing and Coding Article. IOM language has been removed from the body of the policy and the applicable IOM reference has been added under IOM references at the beginning of the policy. Minor wording changes have been made to the indications and limitations sections. There has been no change in content/coverage.	Other (CMS change request)
10/01/2018	R4	LCD revised and published on 10/25/2018 effective for dates of service on and after 10/01/2018 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10-CM code(s) have been deleted and therefore removed from the LCD: R93.8. The following ICD-10-CM code(s) have been added to the LCD Group 1 codes: R93.89, T43.641A, T43.642A, T43.643A, and T43.644A. Per LCD annual review, updated references in the “CMS National Coverage Policy” section, formatting changes were made and headers added throughout the LCD without a change in coverage content, regrouped the CPT codes to align with their respective diagnosis code groups, and added hyperlinks to related LCD, LCA, and NCD in the section for related national and local coverage documents. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; therefore, not all the fields included on the LCD are applicable as noted in this policy.	Revisions Due To ICD-10-CM Code Changes Other (LCD Annual Review)
10/01/2017	R3	LCD revised and published on 10/05/2017 effective for dates of service on and after 10/01/2017 to reflect the ICD-10 Annual Code Updates. The following ICD-10 code(s) have undergone a descriptor change: I50.1, J15.6. The following ICD-10 code(s) have been deleted from Group 1 codes: I27.2, T07; and from Group 2 codes: I27.2. The following ICD-10 code(s) have been added to Group 1 codes: G12.25, I27.20, I27.21, I27.22, I27.23, I27.24, I27.29, I27.83, I50.810, I50.811, I50.812, I50.813, I50.814, I50.82, I50.83, I50.84, I50.89, T07.XXXA; and to Group 2 codes: I27.20, I27.21, I27.22, I27.23, I27.24, I27.29, I27.83, I50.810, I50.811, I50.812, I50.813, I50.814, I50.82, I50.83, I50.84, I50.89*. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; therefore, not all the fields included on the LCD are applicable as noted in this policy.	Revisions Due To ICD-10-CM Code Changes
10/01/2016	R2	LCD revised and published on 09/29/2016 effective for dates of service on and after 10/01/2016 to reflect the ICD-10 Annual Code Updates. The following ICD-10 codes have undergone a descriptor change: T82.817A and T82.818A.	Revisions Due To ICD-10-CM Code Changes
12/11/2015	R1	LCD reviewed for administrative purposes. No changes were made to the LCD itself.	Other (Annual Review)

Associated Documents

Attachments
N/A

Related National Coverage Documents
NCDs
240.2 - Home Use of Oxygen

Public Versions

Updated On	Effective Dates	Status
10/11/2019	10/17/2019 - N/A	Currently in Effect	You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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Oximetry Services

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Note History

Contractor Information

LCD Information

Document Information

Issue

CMS National Coverage Policy

Coverage Guidance

Proposed Process Information

Coding Information

Bill Type Codes

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CPT/HCPCS Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Additional ICD-10 Information

General Information

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