TMPPM 2008 > Texas Medicaid Services > Texas Health Steps (THSteps) > THSteps-Comprehensive Care Program (CCP)

43.4.5.8 Croup Tent/Pulse Oximeter

Croup Tent

The croup tent consists of a plastic tent and humidification system placed over a crib or bed to provide a high humidity environment.

A croup tent requires prior authorization.

Note: Prior authorization is a condition for reimbursement, not a guarantee of payment.

Reimbursement for the croup tent is per month, regardless of whether the therapy is for only one day or one week.

Rental of the croup tent includes purchase of the croup tent canopy, rental of a compressor, set-up charge, and supplies.

Separate payment is not made for individual components.

Procedure code L-E1399 must be used for rental of the croup tent.

Pulse Oximeter

A pulse oximeter is used to monitor the client's body oxygen saturation level for those clients at risk for hypoxia.

A pulse oximeter is a benefit of the Texas Medicaid Program through THSteps-CCP. A higher level pulse oximeter may be reimbursed based on documentation of medical necessity.

A pulse oximeter requires prior authorization.

Note: Prior authorization is a condition for reimbursement, not a guarantee of payment.

A pulse oximeter may be reimbursed for rental only once a month and is limited to a maximum of six months, at which time purchase may be considered for those clients requiring long-term monitoring.

The provider is responsible for retaining a current prescription.

A pulse oximeter rental, including the probes, may be authorized for clients who are one of the following:

•Birth through 20 years of age and ventilator and/or oxygen dependent.

•Weaning from oxygen and/or a ventilator and have other documented medically necessary conditions requiring a pulse oximeter in the home.

A pulse oximeter may be considered for reimbursement for clients birth through 20 years of age with one of the following levels:

•Level One. Basic level monitoring and/or spot checks. Applicable if the client meets at least one the of the following criteria:

•Client is oxygen- and/or ventilator-dependent at least part of the day (Less than eight hours per day).

•Client is clinically stable and able to wean from oxygen and/or ventilator.

•Client has another medically necessary condition requiring monitoring of oxygen saturation.

•There is a caregiver identified and present who has been trained in use of the oximeter and how to respond to readings in a medically safe way.

•Level Two. Providers must use modifier TF when the oximeter device is for intermediate level of care and continuous monitoring. Applicable if the client meets all the following criteria:

•Client is oxygen- and/or ventilator-dependent a significant portion of the day (e.g., 8 to 16 hours per day).

•Client needs continuous monitoring of oxygen saturation during sleep and/or to maintain optimal levels.

•There is a caregiver identified and present who has been trained in use of the oximeter and how to respond to readings in a medically safe way.

•Level Three. Providers must use modifier TG if the oximeter device is for a serious condition and there is critical need for continuous monitoring. Applicable if the client meets all the following criteria:

•Client has frequent need for changes in oxygen and ventilator settings.

•Client is oxygen- and/or ventilator-dependent (e.g., 16 to 24 hours per day).

•Client is in the weaning process from oxygen and/or ventilator and experiencing respiratory complications.

•Client requires equipment that is motion-sensitive, has more complex readouts, or monitoring capabilities.

•There is a caregiver identified and present who has been trained in use of the oximeter and how to respond to readings in a medically safe way.

A pulse oximeter rental is limited to once per month for a maximum of six months. For those clients not requiring long-term monitoring, a rental extension may be considered for up to six months for level two and three oximeters (TF and TG devices). Purchase may be considered for those clients requiring long term monitoring. Before purchase, the provider must supply a new oximeter to the client.

For all requests providers must:

•Submit the completed Pulse Oximeter Form in addition to the required THSteps-CCP Prior Authorization Request Form. (see "Pulse Oximeter Form" and the "THSteps-CCP Prior Authorization Request Form".)

•Clearly indicate medical necessity using the TF and TG modifiers on the Pulse Oximeter Form.

•Continue to use the current code for lease (L-E0445 with modifier RR) and purchase (J-E0445 with modifier NU).

When requesting prior authorization, providers must use the following procedure codes with the appropriate modifier:

Note: Prior authorization is a condition for reimbursement, not a guarantee of payment.

Replacement sensor probes (reusable or disposable) for client-owned oximeters require prior authorization through THSteps-CCP.

Sensor probes are limited to four per month using procedure code 9-A4606. Clients birth through 20 years of age may obtain additional probes with documentation of medical necessity.

Respiratory Care Equipment - THSteps-CCP Procedure Codes and Limitations