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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2 Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.6 Durable Medical Equipment (DME) Supplier (CCP) : 2.6.6 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 TG) may be reimbursed based on documentation of medical necessity. Modifier TG must be submitted in addition to procedure code E0445. Modifier TG is used for complex or 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
CPT only copyright 2014 American Medical Association. All rights reserved.