Medicare Advantage

​Consumer Grade Pulse Oximetry Devices For Use In The Home Setting (June 16, 2021)


Policy Impacted



Policy Impacted

MA05.042a Pulse Oximeter​s in the Home Setting​

Purpose

The purpose of this News Article is to provide advance notice during the COVID-19 outbreak related to the coverage of consumer grade pulse oximetry devices for use in the home setting.

The coverage of consumer grade pulse oximetry devices for use in the home setting is effective from June 1, 2020 and will be reevaluated for continuing applicability on October 31, 2021. 



Background

There is currently an outbreak of respiratory disease caused by a novel coronavirus, which has now been detected both nationally and internationally. The virus has been named “SARS-CoV-2” and the disease it causes has been named “Coronavirus Disease 2019” (COVID-19). The SARS-CoV-2 virus has demonstrated the capability to rapidly spread, leading to significant impacts on healthcare systems and causing societal disruption. The potential public health threat posed by COVID-19 is high globally. To effectively respond to the COVID-19 outbreak, rapid detection of cases and contacts, appropriate clinical management and infection control, and implementation of community mitigation efforts are critical.


Indications

N/A



Coverage Statement

The Company will provide coverage for consumer grade pulse oximetry devices for use in the home setting for patients under investigation (PUI) or with a confirmed diagnosis of COVID-19, under the care of a professional provider when all the following criteria are met:
  • The individual presented with symptoms consistent with COVID-19 (e.g., congestion or runny nose, cough, shortness of breath or difficulty breathing, fatigue, fever or chills, muscle or body aches, headache, sore throat, nausea or vomiting, diarrhea, new loss of taste or smell).
  • The consumer grade pulse oximeter is ordered by a professional provider.
  • The individual or a trained caregiver has the physical and cognitive capacity to monitor their symptoms and to understand the importance of seeking medical guidance should symptoms progress.


REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports.


BILLING REQUIREMENTS FOR CONSUMER GRADE PULSE OXIMETRY DEVICES

Eligible providers supplying consumer grade pulse oximetry devices for use in the home setting must report Healthcare Common Procedure Coding System (HCPCS) code E0445 along with the COVID-19 diagnosis code or diagnosis codes consistent with the symptoms of COVID-19.

Consumer grade pulse oximetry devices may be considered eligible for reimbursement, when supplied by an in-network designated DME supplier, professional provider, or home health agency. Referral requirements for HMO and POS members have been waived for consumer grade pulse oximetry devices when supplied by an eligible provider.

Inclusion of a code in this News Article does not imply reimbursement. Eligibility, benefits, limitations, exclusions, provider contracts, and Company policies apply.


RELATED POLICY BULLETINS

Medical grade pulse oximetry devices in the home setting are addressed in the current versions of the following policy bulletin:

  • MA05.042a Pulse Oximeters in the Home Setting



Dosing and Administration

N/A



Black Box Warnings and/or Contraindications

N/A



Coding

CODE TYPE
CODE(S) AND NARRATIVE(S)
ICD Diagnosis
COVID-19 Diagnosis

U07.1

OR

One or more of the following COVID-19 symptoms. (Note: this list is not all-inclusive)

R05 Cough

R06.00 Dyspnea, unspecified

R06.02 Shortness of breath

R07.0 Pain in throat

R09.81 Nasal congestion

R11.10 Vomiting, unspecified

R11.11 Vomiting without nausea

R19.7 Diarrhea, unspecified

R43.8 Other disturbances of smell and taste

R50.9 Fever, unspecified

R51.9 Headache, unspecified​

R52 Pain, unspecified

R53.83 Other fatigue

R68.83 Chills (without fever)
HCPCS Level II
The Following Code Is Used To Represent Consumer Grade Pulse Oximeter Device when billed with NU Modifier

E0445 Oximeter device for measuring blood oxygen levels noninvasively

Modifier

NU New durable medical equipment purchase





7/17/2020