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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) : 2.4.6 Croup Tent/Pulse Oximeter

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.
The rental of a croup tent (procedure code E1399) is a benefit of Texas Medicaid through CCP. Rental of the croup tent includes purchase of the croup tent canopy, rental of a compressor, setup charge, and supplies.
Separate payment is not made for individual components. Pulse Oximeter
A pulse oximeter (procedure code E0445) is a benefit of Texas Medicaid through CCP. A higher-level pulse oximeter (procedure code E0445 with modifier TF or TG) may be reimbursed based on documentation of medical necessity. Modifier TF or TG must be submitted in addition to procedure code E0445 depending on the level of care. Modifier TF is used for intermediate level of care, and modifier TG for complex/high level of care.
A pulse oximeter rental is limited to once per month for a maximum of six months. For those clients who require long-term monitoring, recertification may be considered for up to a maximum of six additional months. Purchase may be considered when it is determined to be medically necessary and more cost-effective than leasing the device with supplies. Before purchase, the provider must supply a new pulse oximeter to the client.
A pulse oximeter may be reimbursed for purchase once every five years.
The provider is responsible for retaining a current prescription.
The rental of equipment includes all necessary supplies, adjustments, repairs, and replacement parts. Pulse oximeter sensor probes (procedure code A4606) for client-owned equipment are limited to four per month without prior authorization.

Texas Medicaid & Healthcare Partnership
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