CurrentAlliance HealthPolicy 1A-3

NC Medicaid Noninvasive Pulse Oximetry

Defines NC Medicaid coverage, eligibility, and limitations for noninvasive pulse oximetry (including continuous overnight monitoring) for beneficiaries of Alliance Health in North Carolina.

Policy Summary

PayerAlliance Health

PolicyNC Medicaid Noninvasive Pulse Oximetry

Policy CodePolicy 1A-3

Change TypeNo material change

Effective Date

Next Review Date

Key ActionVerify Medicaid eligibility for each service and document continuous overnight monitoring with a preset, non-adjustable device that provides a printable report of sampling hours, percent saturation, and aggregate results.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

No prior approvalprior authorization policy for Medicaid

Not coveredexclusion for routine/asymptomatic testing

EPSDT appliespediatric EPSDT provision

Printable reportdevice documentation requirement

1/1/1989policy origin

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Covered Indications (General and Specific)

Covered when ALL of the following are met:

General medical necessity: The procedure, product, or service is individualized, specific, and consistent with symptoms or a confirmed diagnosis and not in excess of the beneficiary's needs.

based on policy general criteria

Safety and conservatism: The procedure, product, or service can be safely furnished and no equally effective, more conservative, or less costly treatment is available statewide.

based on policy general criteria

Not for convenience: The procedure, product, or service is not furnished primarily for the convenience of the beneficiary, the beneficiary's caretaker, or the provider.

based on policy general criteria

Indications for noninvasive pulse oximetry: Noninvasive pulse oximetry is medically necessary to evaluate conditions commonly associated with oxygen desaturation.

from specific criteria

Continuous overnight monitoring: Continuous overnight pulse oximetry is covered when the beneficiary would otherwise require hospitalization solely for continuous overnight monitoring; the oximeter must be preset, self-sealed, and not adjustable by the beneficiary or anyone in the home; the device must provide a printout documenting an adequate number of sampling hours, percentage of oxygen saturation, and an aggregate of the results; and the test results must be reliable and maintained in the medical record.

from specific criteria

Coverage with Limitations

Coverage rules and limits for noninvasive pulse oximetry

Medicaid coverage conditions: Noninvasive pulse oximetry is covered when medically necessary; routine testing in the absence of signs or symptoms suggestive of desaturation is not covered by Medicaid.N/A

Medicaid does not require prior approval for this service (see coding rules for billing limitations).

Billing and code-specific limits: Report the most specific CPT/HCPCS code that accurately describes the service; if no specific code exists use an appropriate unlisted procedure or service code; CPT codes 94760 and 94761/94762 are the noninvasive pulse oximetry codes and 94760/94761/94762 must be reported per policy; 94760 and 94761 must not be billed when another covered Medicaid service is billed by the same provider on the same date of service.

See coding section for exact code usage and coexistence rules.

Medicaid does not cover services when the beneficiary fails to meet eligibility in Section 2.0, does not meet the medical necessity criteria in Section 3.0, duplicates another provider's procedure/product/service, or when the service is experimental, investigational, or part of a clinical trial. Claims meeting any of these conditions are subject to denial.

Routine testing performed in the absence of signs or symptoms suggestive of oxygen desaturation is excluded from coverage. Such asymptomatic or surveillance pulse oximetry testing is not a covered service under Medicaid and may be denied.

Copayment requirements for Medicaid beneficiaries are governed by the Medicaid State Plan. Providers should refer to the Medicaid State Plan public notice for specific copayment provisions.

Routine pulse oximetry testing in patients without signs or symptoms of desaturation is considered not medically necessary and is not covered by Medicaid.

Medicaid explicitly excludes routine, asymptomatic pulse oximetry testing—testing performed when there are no clinical signs or symptoms suggestive of desaturation—and such services are not covered.

Provider Actions, Documentation & Billing Requirements

Prior Authorization

Prior Approval Requirement

Prior approval is not required for Noninvasive Pulse Oximetry under Medicaid. However, EPSDT does not waive prior approval when a service otherwise requires it — providers must follow EPSDT guidance and NCTracks resources for beneficiaries under 21.

Noninvasive pulse oximetry: no prior approval required (see policy section 5.1).
EPSDT: prior approval requirement remains in effect for services that normally require it; providers should consult NCTracks and the EPSDT provider page for details.

Denial Risk

Denial Triggers

Claims may be denied if the beneficiary is not eligible for Medicaid at the time of service, does not meet the policy criteria, the service duplicates another provider's service, or the service is experimental/investigational. Providers should confirm coverage criteria and avoid submitting duplicate services.

Denial triggers include: beneficiary ineligible per Section 2.0; failure to meet Section 3.0 criteria; duplicate services provided by another provider; services that are experimental or part of a clinical trial.

Denial Risk

Routine Testing Exclusion

Routine testing for pulse oximetry without signs or symptoms suggestive of desaturation is not covered and may be denied. Document clinical indications that support testing to avoid denials.

Routine or surveillance testing in the absence of signs/symptoms of desaturation is excluded from coverage.

Documentation Required

Eligibility Verification

Providers must verify each beneficiary's Medicaid eligibility at the time services are rendered. Eligibility limitations by category may affect coverage for this service.

Verify Medicaid eligibility at time of service.
Be aware some eligibility categories restrict coverage for certain services.

Billing Rule

Coding and Documentation Specificity

Report ICD-10-CM/PCS and procedure codes to the highest level of specificity that supports medical necessity. Use current CPT, HCPCS, and UB-04 revenue codes; when no specific code exists, use the appropriate unlisted code. Note that CPT codes 94760 and 94761 must not be billed when another covered Medicaid service is billed by the same provider on the same date of service.

Report ICD-10-CM/PCS codes to highest specificity supporting medical necessity.
Use current CPT/HCPCS/UB-04 editions for procedure and revenue coding.
If no specific code exists, report the appropriate unlisted procedure/service code.
94760 and 94761 must not be billed when another covered Medicaid service is billed by the same provider on the same date of service.

Documentation Required

Compliance Obligations

Providers must comply with all applicable agreements, federal, state and local laws and regulations (including HIPAA), NC Medicaid policies, provider manuals, implementation updates, and applicable record retention requirements.

Comply with HIPAA and record retention requirements.
Adhere to NC Medicaid clinical coverage policies, provider manuals, CMS/DHHS guidance, and contractor bulletins.

Billing Rule

Required Billing Documentation

Providers shall bill usual and customary charges and report the appropriate procedure code(s) which determine billing units. For place of service, use one of the allowed settings. Refer to NC Medicaid reimbursement resources for rate schedules and billing guidance.

Report appropriate code(s) that determine billing units.
Place of Service must be one of: Inpatient Hospital, Outpatient Hospital, Office, Home.
Bill usual and customary charges; see NC Medicaid rate schedule for reimbursement details.

Note

Provider Qualifications

No special provider qualifications or certifications apply beyond participating as a Medicaid provider and adhering to licensing rules.

No provider-specific qualifications or certifications required for performing noninvasive pulse oximetry beyond standard Medicaid participation and applicable occupational licensing.

Definitions

Noninvasive pulse oximetry definition — measurement description

DefinitionNoninvasive pulse oximetry measures arterial oxygen saturation by a probe that assesses light absorption of oxygenated hemoglobin and total hemoglobin in arterial blood.

Measurement methodDetermines oxygen saturation by analyzing light absorption characteristics of hemoglobin

Device typeExternal probe applied to a patient (noninvasive) to estimate arterial oxygen saturation

EPSDT — definition and application for beneficiaries under 21

DefinitionEPSDT (Early and Periodic Screening, Diagnostic, and Treatment) is a federal Medicaid requirement to cover medically necessary services for beneficiaries under 21 to correct or ameliorate health problems identified through screening or evaluation.

ScopeEPSDT may require exceeding standard policy limits for scope, amount, duration, frequency, or location if provider documentation shows the service is medically necessary to correct or improve the beneficiary's health.

LimitationsEPSDT does not obligate the state to provide services that are unsafe, ineffective, or experimental/investigational, or not medical in nature.

Routine testing — definition (absence of signs/symptoms) and exclusion

DefinitionRoutine testing: testing performed in the absence of signs or symptoms suggestive of desaturation.

Coverage exclusionMedicaid shall not cover routine testing when there are no signs or symptoms suggestive of desaturation.

Denial riskClaims for routine/asymptomatic testing risk denial as not medically necessary under this policy.

OpenPayer

NC Medicaid Noninvasive Pulse Oximetry

Coverage Criteria for Noninvasive Pulse Oximetry

Coding and Billing Codes

Provider Actions, Documentation & Billing Requirements

Background

Definitions

94760	Noninvasive pulse oximetry (per policy references)
94761	Noninvasive pulse oximetry (per policy references)
94762	Noninvasive pulse oximetry (per policy references)