Table of Contents Previous Next Index

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 : 2.4.6.2 Prior Authorization and Documentation Requirements

2.4.6.2
2.4.6.2.1 Croup Tent
A croup tent requires prior authorization. A completed CCP prior authorization form and documentation to support medical necessity must be submitted to CCP prior authorization unit.
Reimbursement for the croup tent is limited to monthly rental, regardless of whether the therapy is medically necessary for only one day or one week.
2.4.6.2.2 Pulse Oximeter
A pulse oximeter requires prior authorization.
A pulse oximeter may be considered for prior authorization for clients who are birth through 20 years of age who are CCP-eligible when documentation submitted clearly shows that the equipment is medically necessary and will correct or ameliorate the client’s disability or physical or mental illness or condition. Documentation must include the following for the level requested:
Level One. Basic level monitoring capable of spot checks and heart rate. Applicable if there is a caregiver or medical provider identified and present who has been trained in use of the oximeter and how to respond to readings in a medically safe way and the client meets at least one the of the following criteria:
Level Two. Providers must use modifier TF when the oximeter device is for intermediate level of care and continuous monitoring, alarm, memory, and correction of motion artifact. Applicable if the client meets all the following criteria:
There is a caregiver or medical provider 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:
There is a caregiver or medical provider identified and present who has been trained in use of the oximeter and how to respond to readings in a medically safe way.
For all requests providers must:
A pulse oximeter rental includes the system, the sensor probes, and all necessary supplies.
Pulse oximeter sensor probes (procedure code A4606) for client-owned equipment are limited to four per month without prior authorization. Providers may obtain additional probes for clients who are birth through 20 years of age with documentation of medical necessity. Additional probes require prior authorization through CCP.

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