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2012 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2. Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.4 Durable Medical Equipment (DME) Supplier (CCP) : 2.4.5 Cardiorespiratory (Apnea) Monitor

Cardiorespiratory (Apnea) Monitor
Apnea monitors are a benefit of CCP for clients who are birth through 20 years of age. The purchase of an apnea monitor (procedure code E0618 or E0619) is limited to once every five years. The rental of an apnea monitor (procedure code E0619) is limited to once per month.
The rental of an apnea monitor with recording feature may be considered for two months without prior authorization for infants up to 4 months of age with one of the following diagnosis codes.
Diagnosis code 42789 includes atrial tachycardia (supraventricular tachycardia [SVT], atrioventricular [AV] nodal reentry, nodal, and sinoauricular) and bradycardia (nodal, sinoatrial).
Other diagnoses may be considered for prior authorization based on medical necessity. Use of diagnosis code V198 may be considered on appeal, and requires submission of additional documentation to support medical necessity.
Procedure code 94774 may be used by the physician to bill for the interpretation of the apnea monitor recordings.
Electrodes and lead wires (procedure codes A4556 and A4557) for the apnea monitor are a benefit only if the apnea monitor is owned by the client. Additional documentation such as the purchase date, the serial number, and purchasing entity may be requested. Procedure code A4556 may be considered for purchase for a maximum of 15 pairs per month. Procedure code A4557 may be considered for purchase for a maximum of two pairs per month. Additional lead wires may be requested on appeal with documentation of medical necessity. The physician must provide medical necessity for the electrodes, lead wires, and a statement that the client owns the monitor. If the apnea monitor is rented, the electrodes and lead wires are considered part of the rental fee.
The apnea monitor/pulse oximeter combination device is not a benefit of Texas Medicaid.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.