group 1 - instant diagnostic · re: pulse-oximetry ... oxygen under medicare group 1 criteria...

GROUP 1

Instant Diagnostic Systems, Inc

1740 4th Ave SE, Suite A, Decatur, AL 35601Mail to: PO Box 2449, Decatur, AL 35602

Phone: (800)355-0691 Fax: (888)771-5146www.instantdiagnostic.com

PATIENTJANE DOE Tel: (404) 404-4040 DoB: 7/31/1997

ORDERING PHYSICIAN DEMO INTERP Fax: (734) 843-7718

HMEDEMONSTRATION DME ACCOUNT Tel: (800) 355-0691 Fax: (256) 922-1020

RE: Pulse-Oximetry Test Results Attached -- Report #1769597

- Oxygen Qualification Status: - Results suggest patient qualifies for stationary oxygen under Medicare Group 1 criteria because arterial oxygen saturation was at or below 88% for at least 5 minutes. (Does not have to be consecutive). [1]

Attached is a single page SUMMARY REPORT. You were originally faxed the single page version of this test report because IDS files indicate it is your preference. If you need the expanded version of this single report, call IDS customer service at 800-355-0691. If you would like to change this preference to receive expanded reports for ALL tests in the future, sign or initial below fax back to IDS at 888-771-5146.

- SET FAX PREFERENCE TO FULL (6+ pg) Reports - INITIAL HERE: _______

Alert:Upload performed in 'DEMO' mode. Some errors will treated as warnings. Alert:Device - Oximetry test started before prescription created

CONFIDENTIALITY NOTICE: This fax is intended for the sole use of the individual(s) to whom it is addressed, and may contain information that is privileged, confidential, and exempt from disclosure under applicable law. You are hereby notified that any dissemination, duplication, or distribution of this transmission by someone other than the intended addressee or its designated agent is strictly prohibited. If you receive this fax in error, please notify IDS immediately at 1-800-355-0691. FOOTNOTES: [1] Oxygen Qualifcation Status Definiitions and Disclaimer: Auto generated statements based on Medicare Stationary O2 coverage policies: Group I: Initial O2 Coverage for 1 year; Spo2 must be at or below 88% for 5 total minutes during sleep, or must fall 5% below the baseline (mean) for 5 minutes (requires signs and symptoms). - Group 2: Initial O2 Coverage for 3 months; SpO2 must be at or below 89 for 5 total minutes. - Group 3: No Oxygen Coverage. Spo2 didnt meet the previously listed requirements. Disclaimer: These statements are NOT intended to diagnose any disease or determine the medical need for Oxygen or final Medicare and/or insurance coverage for oxygen therapy or any other treatment. Physicians must carefully review the oximetry data, clinical information, and comorbid illnesses in conjunction with all Medicare criteria to determine if the patient should receive oxygen therapy.[2] Explanation of Excluded Data and Artifact: As this test is intended to be recorded while the patient is asleep, the first 5 minutes and last one minute of each recording session are assumed to be "wake" time and are excluded from calculations unless otherwise specified. Artifact is defined as: Spo2 <40; Spo2 >100; Pulse <0 or Pulse > 220 and is excluded from calculations in this report. Pulse-Oximeters have built-in algorithms to identify motion artifact within the recording. Data points identified as such are excluded from IDS reports as well. [3] Explanation of Awake or Wake Statistics: "Wake" statistics are calculated during the first 5 minutes of test data (immediately after the device is powered on), when it is assumed the patient is awake. True wake/sleep state cannot be determined in unattended pulse-oximetry. [4] 4% Desaturation Events: Defined as a drop in SpO2 of greater than or equal to 4 percentage points from any peak saturation level within a 2 minute window (i.e. a drop from 99% to 95% within a 2 minute period would be a 4% desat event). The event's duration ends when the saturation level makes an upward movement ,or when invalid or artifact data is encountered. *Events with duration of over 3 minutes are excluded. [5] Deep Desaturation Events: Events where oxygen saturations levels fell deeply - by more than 5% - within a 2 minute window from any peak saturation level (i.e. a drop from 99% to 93% within a 2 minute period will be listed here as a deep desat event). The events end when the saturation level makes an upward movement or invalid/artifact data is encountered. Events with duration over 3 minutes are excluded.[6] Sessions: A single study may be made op of multiple "sessions" from a single pulse-oximeter. A session begins each time the pulse-oximeter is powered on, and ends any time the oximeter is powered off (intentionally or unintentionally).

Page 1 of 6Overnight Pulse Oximetry Report - 1769597 - JANE DOE

7/31/2012




PULSE-OXIMETRY REPORT #1769597: Nocturnal test performed while on room air.

PATIENTJANE DOE 1316 COMMERCE DR DECATUR, AL 35601-7539 Tel: (404) 404-4040 DoB: 7/31/1997

ORDERING PHYSICIAN DEMO INTERP NPI: 0000000000 Fax: (734) 843-7718

INSURANCE: Medicare

HMEDEMONSTRATION DME ACCOUNT 1316 COMMERCE DR. N.W. SUITE A ATLANTA, GA 30301 Tel: (800) 355-0691 Fax: (256) 922-1020

Start: 7/29/2012 8:52 PM - End: 7/30/2012 5:30 AM - Duration: 08:00:00 - Excluded[2]: 00:00:44 - Total Valid: 07:59:16

OXYGEN SATURATION (SPO2) SUMMARY

Spo2 Time, % Overall Spo2 Time, % Overall Overall High: 97 Wake[3] High: 95≥ 90% : 06:31:28,81.7% ≤ 80% : 00:00:08, 0.0% Overall Low: 80 Wake Low: 92≤ 89% : 01:27:48, 18.3% ≤ 70% : 00:00:00, 0.0% Overall Baseline: 91.8 Wake Avg: 94≤ 88% : 01:14:16, 15.5% ≤ 60% : 00:00:00, 0.0% Std. Deviation: 2.818

- Spo2 Fell more than 5% below baseline of 91.8 for total of: 00:41:36- Longest continuous period with SpO2 <= 88% was: 00:05:04 - Oxygen Desaturation Index (4% ODI): 7.887

PULSE SUMMARY

High : 92 Low : 55

Average Pulse : 65.4 Pulse Std.Dev.: 6.365

OXYGEN QUALIFICATION STATUS [1]

Results suggest patient qualifies for stationary oxygen under Medicare Group 1 criteria because arterial oxygen saturation was at or below 88% for at least 5 minutes. (Does not have to be consecutive). [1] NOTE: Patient Insurance on file is: Medicare

Oximeter: R920M, Serial #123456789, Uploaded: 7/31/2012 2:28:00 PM; Ax-2.0.8- WIN32, IDS-2.1.2010.01.13, Rpt-07/31/2012


7/31/2012

PULSE-OXIMETRY REPORT #1769597: JANE DOE

SPO2 Histogram

Lists total cumulative time measured for each recorded Spo2 level. Value Duration Value Duration Value Duration

80 00:00:08 87 00:19:40 94 01:57:5681 00:00:12 88 00:13:00 95 00:23:3282 00:00:48 89 00:13:32 96 00:03:3283 00:01:32 90 00:17:56 97 00:00:4084 00:07:04 91 00:36:44 Artifact 00:00:4485 00:12:20 92 01:01:0486 00:19:32 93 02:10:04

Sessions [6]

SESSION NUMBER :: 001 of 1 for Rpt# 1769597 - JANE DOEStart : 7/29/2012 8:52 PM High Pulse : 92 High SpO2 : 97

End : 7/30/2012 5:30 AM Low Pulse : 55 Low SpO2 : 80

Total : 08:00:00 Avg. Pulse : 65.4 Avg. SpO2 : 91.8


7/31/2012


4% DESATURATION EVENT[4] STATISTICS

- 4% Oxygen Desaturation Index (ODI): 7.887 - Total Events: 63 - Average Event Duration: 37.016(seconds)

- Mean Onset SpO2: 91.889 - Mean Low SpO2: 87.175 - SpO2 fell to 88% or less in: 38 events.

- 0 events were excluded due to duration > 3 minutes

DEEP DESATURATION EVENT[5] LIST:

Lists events where Spo2 fell by more than 5% within 2 minute window. These events are marked on graphs by id#. ID Start End Duration SPO2 Onset SPO2 Low Pulse High Pulse Low1 9:16:52 PM 9:17:28 PM 00:00:36 94 85 81 622 9:22:32 PM 9:23:44 PM 00:01:12 92 85 70 603 9:24:24 PM 9:24:52 PM 00:00:28 91 84 72 594 10:55:20 PM 10:57:08 PM 00:01:48 94 84 80 665 11:05:56 PM 11:06:28 PM 00:00:32 92 84 75 676 11:11:00 PM 11:11:16 PM 00:00:16 92 86 67 637 11:23:40 PM 11:24:08 PM 00:00:28 92 85 74 648 11:24:52 PM 11:26:36 PM 00:01:44 88 82 74 659 11:30:16 PM 11:32:00 PM 00:01:44 88 80 72 65

10 11:34:52 PM 11:35:12 PM 00:00:20 91 85 66 6211 11:49:32 PM 11:49:56 PM 00:00:24 95 89 70 6312 12:47:40 AM 12:48:12 AM 00:00:32 91 84 70 6313 12:51:56 AM 12:52:16 AM 00:00:20 88 82 69 6814 12:53:48 AM 12:54:04 AM 00:00:16 91 84 66 6515 12:55:16 AM 12:55:48 AM 00:00:32 93 86 75 6416 2:31:04 AM 2:31:40 AM 00:00:36 94 85 82 7517 2:37:36 AM 2:38:00 AM 00:00:24 91 85 80 7418 2:42:44 AM 2:44:12 AM 00:01:28 91 85 84 7219 2:48:36 AM 2:48:52 AM 00:00:16 90 84 73 7220 2:52:04 AM 2:53:08 AM 00:01:04 90 84 78 6821 3:02:00 AM 3:03:36 AM 00:01:36 91 84 79 7422 3:05:24 AM 3:07:28 AM 00:02:04 90 84 78 6823 3:15:24 AM 3:16:44 AM 00:01:20 89 83 79 71

The following statistics summarize the "Deep Desaturation Events" list[5] above for rpt# 1769597 - JANE DOE

- Deep events per hour: 2.879 - Total Events: 23 - Average Event Duration: 52.174 (seconds) - Cumulative time: 00:20:00

- SpO2 fell to 88% or less 22 times - Mean Onset (High) Spo2: 91.217 - Mean Low Spo2: 84.304 - 0 events excluded (Duration > 3 mins)


7/31/2012



7/31/2012

GROUP 1Alternate

Qualification(5% Rule)




PATIENT JAMES DOE Tel: (404) 404-4040 DoB: 8/24/1933 Age: 79

ORDERING PHYSICIAN DEMO Doctor NPI: 0000000000 Fax: (734) 843-7718

HME DEMONSTRATION DME ACCOUNT Tel: (800) 355-0691 Fax: (256) 922-1020

RE: Pulse-Oximetry Test Results Attached -- Report #1794280 - Oxygen Qualification Status[1] : - Results suggest patient may qualify for stationary oxygen under Medicare Group 1 criteria because arterial oxygen saturation decreased by more than 5 percent from baseline for at least 5 minutes. Requires 2hrs valid time & must be associated with signs and symptoms reasonably attributable to hypoxemia. Reference Medicare criteria. [1] - Prefer a single page report? You can now choose to receive only the summary page (page 1) of IDS pulse-oximetry reports! This page contains the most commonly used data as well as all necessary data to calculate O2 qualification per CMS guidelines. If you choose this option, IDS will continue to generate the full report and keep it on file, available upon request. To enable this feature for future studies, simply initial here and fax back to IDS at 888-771-5146. - FAX SINGLE PAGE REPORTS - PHYSICIAN INITIAL HERE: _______

Alert:Upload performed in 'DEMO' mode. Some errors will treated as warnings.

CONFIDENTIALITY NOTICE: This fax is intended for the sole use of the individual(s) to whom it is addressed, and may contain information that is privileged, confidential, and exempt from disclosure under applicable law. You are hereby notified that any dissemination, duplication, or distribution of this transmission by someone other than the intended addressee or its designated agent is strictly prohibited. If you receive this fax in error, please notify IDS immediately at 1-800-355-0691. FOOTNOTES: [1] Oxygen Qualifcation Status Disclaimer and Definitions: Disclaimer: The auto-generated Oxygen Qualification statements in this report are NOT intended to diagnose any disease, determine the medical need for Oxygen, or determine final Medicare and/or insurance coverage for oxygen therapy or any other treatment. Physicians must carefully review the oximetry data, clinical information, and comorbid illnesses in conjunction with allcurrent Medicare criteria to determine if the patient should receive oxygen therapy. Definitions: Group 1, Method 1: Initial O2 Coverage for 1 year; Spo2 must be at or below 88% for 5 total minutes during sleep. Method 2:- Spo2 must fall 5% below the overall mean for 5 minutes (requires 2hrs data + signs and symptoms attributable to Hypoxemia). Group 2: Initial O2 Coverage for 3 months; SpO2 must be at or below 89% for 5 total minutes during sleep. Also requires one of the following: 1. Dependent edema sugg of CHF 2. Pulm. hypertension or cor pulmonale 3. Erythrocythemia (hematocrit > 56). Group 3: No Oxygen Coverage. Spo2 didn't meet coverage criteria. [2] Explanation of Excluded Data and Artifact: As this test is intended to be recorded while the patient is asleep, the first 5 minutes and last one minute of each recording session are assumed to be "wake" time and are excluded from calculations unless otherwise specified. Artifact is defined as: Spo2 <40; Spo2 >100; Pulse <0 or Pulse > 220 and excluded from calculations in this report. Pulse-Oximeters have built-in algorithms to identify motion artifact within the recording. Data points identified as such are excluded from IDS reports as well. [3] Explanation of Awake or Wake Statistics: Because wake/sleep state cannot be determined in unattended pulse-oximetry, "Wake" statistics are derived from the first 5 minutes of test data when it is assumed the patient is awake (using only the first session in chronological order when multiple sessions are present[6]). This same 5 minutes of 'wake' data is excluded[2] from the remainder of stats in the test report. [4] 4% Desaturation Events: Events where SpO2 falls by at least 4 percentage points from any peak saturation level within a 2 minute window (i.e. a drop from 99% to 95% within a 2 minute period would be a 4% desat event). The event's duration ends when the saturation level makes an upward movement, or when invalid or artifact data is encountered. *Events with duration of over 3 minutes are excluded. [5] Deep Desaturation Events: Events where oxygen saturations levels fell deeply - by more than 5% - within a 2 minute window from any peak saturation level (i.e. a drop from 99% to 93% within a 2 minute period will be listed here as a deep desat event). The events end when the saturation level makes an upward movement or invalid/artifact data is encountered. Events with duration over 3 minutes are excluded. [6] Sessions: A single study may be made up of multiple "sessions" from a single pulse-oximeter. A session begins each time the pulse-oximeter is powered on, and ends any time the oximeter is powered off (intentionally or unintentionally).

Page 1 of 7Overnight Pulse Oximetry Report - 1794280 - JAMES DOE

8/24/2012




PULSE-OXIMETRY REPORT #1794280: Nocturnal test performed while on room air.

PATIENT JAMES DOE 1316 COMMERCE DR DECATUR, AL 35601-7539 Tel: (404) 404-4040 DoB: 8/24/1933 Age: 79

ORDERING PHYSICIAN DEMO Doctor NPI: 0000000000 Fax: (734) 843-7718 INSURANCE: Medicare Advantage: Aetna Medicare

HME DEMONSTRATION DME ACCOUNT 1316 COMMERCE DR. N.W. SUITE A ATLANTA, GA 30301 Tel: (800) 355-0691 Fax: (256) 922-1020

Start: 8/24/2012 12:06 AM - End: 8/24/2012 6:29 AM - Duration: 06:23:40 - Excluded[2]: 00:00:12 - Total Valid: 06:23:28


Spo2 Time, % Overall Spo2 Time, % Overall Overall High: 98 Wake[3] High: 97≥ 90% : 06:17:04, 98.3% ≤ 80% : 00:00:12, 0.1% Overall Low: 79 Wake Low: 93≤ 89% : 00:06:24, 1.7% ≤ 70% : 00:00:00, 0.0% Overall Baseline: 94.1 Wake Avg: 95.3≤ 88% : 00:04:28, 1.2% ≤ 60% : 00:00:00, 0.0% Std. Deviation: 1.656

- Spo2 Fell more than 5% below baseline of 94.1 for total of: 00:06:24 - Longest continuous period with SpO2 <= 88% was: 00:00:16 - Oxygen Desaturation Index (4% ODI): 8.606

PULSE SUMMARY

High : 110 Low : 64



Results suggest patient may qualify for stationary oxygen under Medicare Group 1 criteria because arterial oxygen saturation decreased by more than 5 percent from baseline for at least 5 minutes. Requires 2hrs valid time & must be associated with signs and symptoms reasonably attributable to hypoxemia. Reference Medicare criteria. [1] Insurance on file: Medicare Advantage: Aetna Medicare

Oximeter: N8500, Serial #1231231231231231, Uploaded: 8/24/2012 3:30:00 PM; Ax-2.0.8- WIN32, IDS-2.1.2010.01.13, Rpt-08/24/2012


8/24/2012

- Spo2 Fell more than 5% below baseline of 94.1 for total of: 00:06:24

PULSE-OXIMETRY REPORT #1794280: JAMES DOE (Age 79)

SPO2 Histogram

Lists total cumulative time measured for each recorded SpO2 level. Value Duration Value Duration Value Duration

79 00:00:04 86 00:00:56 93 01:11:5280 00:00:08 87 00:00:48 94 01:58:4081 00:00:08 88 00:01:20 95 01:24:0482 00:00:12 89 00:01:56 96 00:58:2083 00:00:04 90 00:03:12 97 00:07:2084 00:00:16 91 00:05:12 98 00:01:4485 00:00:32 92 00:26:40 Artifact 00:00:12

Sessions [6]

SESSION NUMBER :: 001 of 1 for Rpt# 1794280 - JAMES DOEStart : 8/24/2012 12:06 AM High Pulse : 110 High SpO2 : 98




8/24/2012



- 4% Oxygen Desaturation Index (ODI): 8.606 events per hour - Total Events: 55 - Average Event Duration: 38.836(seconds)




Lists events where Spo2 fell by more than 5% within 2 minute window. These events are marked on graphs by id#. ID Start End Duration SPO2 Onset SPO2 Low Pulse High Pulse Low1 1:55:44 AM 1:56:12 AM 00:00:28 97 91 94 752 2:07:24 AM 2:08:16 AM 00:00:52 98 92 99 873 3:57:08 AM 3:57:28 AM 00:00:20 97 90 96 844 4:31:24 AM 4:32:08 AM 00:00:44 94 88 92 885 4:34:16 AM 4:34:32 AM 00:00:16 92 86 93 656 4:36:20 AM 4:36:36 AM 00:00:16 90 80 93 777 4:37:16 AM 4:37:56 AM 00:00:40 94 88 93 658 4:38:24 AM 4:38:36 AM 00:00:12 92 86 89 679 4:39:36 AM 4:41:00 AM 00:01:24 94 83 95 69

10 4:41:28 AM 4:41:48 AM 00:00:20 95 87 91 7511 4:42:56 AM 4:43:12 AM 00:00:16 94 87 92 8512 4:43:36 AM 4:44:04 AM 00:00:28 96 90 91 6913 4:45:04 AM 4:46:52 AM 00:01:48 96 88 93 6714 4:48:12 AM 4:48:40 AM 00:00:28 92 85 91 6715 4:48:56 AM 4:49:12 AM 00:00:16 93 85 96 8416 4:50:04 AM 4:50:16 AM 00:00:12 94 88 91 6817 4:52:04 AM 4:52:16 AM 00:00:12 89 81 96 9118 4:53:52 AM 4:54:20 AM 00:00:28 95 84 89 6619 4:54:44 AM 4:55:32 AM 00:00:48 96 87 92 7020 4:56:16 AM 4:56:28 AM 00:00:12 94 87 89 6621 4:57:00 AM 4:57:20 AM 00:00:20 93 86 92 6822 4:58:52 AM 4:59:12 AM 00:00:20 90 79 103 6923 4:59:40 AM 5:01:08 AM 00:01:28 98 91 92 7424 5:55:36 AM 5:56:52 AM 00:01:16 94 84 89 6825 5:58:08 AM 5:58:28 AM 00:00:20 93 86 86 6426 5:58:52 AM 5:59:08 AM 00:00:16 95 86 91 7527 6:17:00 AM 6:18:52 AM 00:01:52 98 92 77 70

The following statistics summarize the "Deep Desaturation Events" list[5] above for rpt# 1794280 - JAMES DOE




8/24/2012



8/24/2012

GROUP 2




PATIENT JANE DOE Tel: (404) 404-4040 DoB: 8/13/1986 Age: 26

ORDERING PHYSICIAN DEMO INTERP NPI: 0000000000 Fax: (734) 843-7718


RE: Pulse-Oximetry Test Results Attached -- Report #1782008 - Oxygen Qualification Status[1] : - Results suggest patient may qualify for stationary oxygen under Medicare Group 2 criteria because: Arterial oxygen saturation was at or below 89% for at least 5 minutes. Also requires one of the following: 1. Dependent edema sugg of CHF 2. Pulm. hypertension or cor pulmonale 3. Erythrocythemia (hematocrit > 56). Reference Medicare criteria. [1] SUMMARY REPORT FAX: You were originally faxed the single page version of this test report because IDS files indicate it is your preference. If you need the expanded version of this single report, call IDS customer service at 800-355-0691. If you would like to change this preference to receive expanded reports for ALL tests in the future, sign or initial below and fax back to IDS at 888-771-5146. - FAX FULL (6+ pg) REPORTS - PHYSICIAN INITIAL: _______

Comments: Patient tested on Resmed AutoPap set to 5 - 20 to determine need for o2 + PAP therapy Alert:Upload performed in 'DEMO' mode. Some errors will treated as warnings. Alert:Device - Duplicate data. Data with the same start and end times and valid time has already been uploaded to prescription 1787922

CONFIDENTIALITY NOTICE: This fax is intended for the sole use of the individual(s) to whom it is addressed, and may contain information that is privileged, confidential, and exempt from disclosure under applicable law. You are hereby notified that any dissemination, duplication, or distribution of this transmission by someone other than the intended addressee or its designated agent is strictly prohibited. If you receive this fax in error, please notify IDS immediately at 1-800-355-0691. FOOTNOTES: [1] Oxygen Qualifcation Status Disclaimer and Definitions: Disclaimer: The auto-generated Oxygen Qualification statements in this report are NOT intended to diagnose any disease, determine the medical need for Oxygen, or determine final Medicare and/or insurance coverage for oxygen therapy or any other treatment. Physicians must carefully review the oximetry data, clinical information, and comorbid illnesses in conjunction with allcurrent Medicare criteria to determine if the patient should receive oxygen therapy. Definitions: Group 1, Method 1: Initial O2 Coverage for 1 year; Spo2 must be at or below 88% for 5 total minutes during sleep. Method 2:- Spo2 must fall 5% below the overall mean for 5 minutes (requires 2hrs data + signs and symptoms attributable to Hypoxemia). Group 2: Initial O2 Coverage for 3 months; SpO2 must be at or below 89% for 5 total minutes during sleep. Also requires one of the following: 1. Dependent edema sugg of CHF 2. Pulm. hypertension or cor pulmonale 3. Erythrocythemia (hematocrit > 56). Group 3: No Oxygen Coverage. Spo2 didn't meet coverage criteria. [2] Explanation of Excluded Data and Artifact: As this test is intended to be recorded while the patient is asleep, the first 5 minutes and last one minute of each recording session are assumed to be "wake" time and are excluded from calculations unless otherwise specified. Artifact is defined as: Spo2 <40; Spo2 >100; Pulse <0 or Pulse > 220 and excluded from calculations in this report. Pulse-Oximeters have built-in algorithms to identify motion artifact within the recording. Data points identified as such are excluded from IDS reports as well. [3] Explanation of Awake or Wake Statistics: Because wake/sleep state cannot be determined in unattended pulse-oximetry, "Wake" statistics are derived from the first 5 minutes of test data when it is assumed the patient is awake (using only the first session in chronological order when multiple sessions are present[6]). This same 5 minutes of 'wake' data is excluded[2] from the remainder of stats in the test report. [4] 4% Desaturation Events: Events where SpO2 falls by at least 4 percentage points from any peak saturation level within a 2 minute window (i.e. a drop from 99% to 95% within a 2 minute period would be a 4% desat event). The event's duration ends when the saturation level makes an upward movement, or when invalid or artifact data is encountered. *Events with duration of over 3 minutes are excluded. [5] Deep Desaturation Events: Events where oxygen saturations levels fell deeply - by more than 5% - within a 2 minute window from any peak saturation level (i.e. a drop from 99% to 93% within a 2 minute period will be listed here as a deep desat event). The events end when the saturation level makes an upward movement or invalid/artifact data is encountered. Events with duration over 3 minutes are excluded. [6] Sessions: A single study may be made up of multiple "sessions" from a single pulse-oximeter. A session begins each time the pulse-oximeter is


8/24/2012

powered on, and ends any time the oximeter is powered off (intentionally or unintentionally).




PULSE-OXIMETRY REPORT #1782008: Nocturnal test performed while on room air.Comments: Patient tested on Resmed AutoPap set to 5 - 20 to determine need for o2 + PAP therapy

PATIENT JANE DOE 1316 COMMERCE DR DECATUR, AL 35601-7539 Tel: (404) 404-4040 DoB: 8/13/1986 Age: 26

ORDERING PHYSICIAN DEMO INTERP NPI: 0000000000 Fax: (734) 843-7718 INSURANCE: Medicare


Start: 8/24/2012 5:07 AM - End: 8/24/2012 12:28 PM - Duration: 07:21:12 - Excluded[2]: 00:01:08 - Total Valid: 07:20:04




PULSE SUMMARY

High : 129 Low : 66



Results suggest patient may qualify for stationary oxygen under Medicare Group 2 criteria because: Arterial oxygen saturation was at or below 89% for at least 5 minutes. Also requires one of the following: 1. Dependent edema sugg of CHF 2. Pulm. hypertension or cor pulmonale 3. Erythrocythemia (hematocrit > 56). Reference Medicare criteria. [1] Insurance on file: Medicare

Oximeter: R920M, Serial #127011824, Uploaded: 8/24/2012 3:10:00 PM; Ax-1.0.18- WIN32, IDS-2.1.2010.01.13, Rpt-08/24/2012


8/24/2012

PULSE-OXIMETRY REPORT #1782008: JANE DOE (Age 26)

SPO2 Histogram


86 00:00:16 91 01:14:04 96 00:09:5287 00:00:20 92 01:37:28 97 00:02:0488 00:01:24 93 01:39:28 98 00:00:2889 00:11:56 94 01:02:24 99 00:00:0890 00:51:36 95 00:28:36 Artifact 00:01:08

Sessions [6]

SESSION NUMBER :: 001 of 1 for Rpt# 1782008 - JANE DOEStart : 8/24/2012 5:07 AM High Pulse : 129 High SpO2 : 99

End : 8/24/2012 12:28 PM Low Pulse : 66 Low SpO2 : 86



8/24/2012



- 4% Oxygen Desaturation Index (ODI): 15.952 events per hour- Total Events: 117 - Average Event Duration: 42.598(seconds)




Lists events where Spo2 fell by more than 5% within 2 minute window. These events are marked on graphs by id#. ID Start End Duration SPO2 Onset SPO2 Low Pulse High Pulse Low1 5:12:36 AM 5:13:36 AM 00:01:00 97 91 94 882 6:01:56 AM 6:02:28 AM 00:00:32 97 91 109 973 6:54:20 AM 6:56:04 AM 00:01:44 96 90 100 784 7:14:28 AM 7:16:12 AM 00:01:44 97 91 91 845 7:25:36 AM 7:27:04 AM 00:01:28 98 92 129 1026 7:49:56 AM 7:50:32 AM 00:00:36 95 89 88 787 8:06:20 AM 8:07:12 AM 00:00:52 96 90 105 828 8:19:52 AM 8:20:24 AM 00:00:32 96 90 90 859 8:28:16 AM 8:30:20 AM 00:02:04 95 89 90 76

10 8:32:32 AM 8:34:00 AM 00:01:28 98 92 109 8511 9:20:12 AM 9:20:56 AM 00:00:44 96 90 88 7912 9:37:16 AM 9:38:12 AM 00:00:56 97 91 82 7513 9:46:28 AM 9:46:48 AM 00:00:20 94 88 83 7614 9:49:44 AM 9:50:36 AM 00:00:52 94 88 85 7215 9:52:12 AM 9:53:32 AM 00:01:20 94 87 97 7616 9:53:52 AM 9:54:36 AM 00:00:44 97 91 87 7517 9:57:44 AM 9:58:44 AM 00:01:00 96 90 91 7818 9:59:36 AM 10:00:48 AM 00:01:12 97 91 84 7319 11:10:36 AM 11:10:52 AM 00:00:16 96 90 86 7720 11:44:56 AM 11:46:20 AM 00:01:24 96 90 87 7521 11:49:40 AM 11:51:12 AM 00:01:32 92 86 98 8222 11:53:48 AM 11:55:00 AM 00:01:12 95 88 84 7023 11:59:08 AM 12:01:12 PM 00:02:04 97 91 86 7124 12:07:52 PM 12:08:40 PM 00:00:48 96 90 92 7325 12:09:16 PM 12:11:00 PM 00:01:44 96 90 91 8126 12:12:56 PM 12:14:36 PM 00:01:40 97 91 91 8027 12:26:20 PM 12:28:24 PM 00:02:04 93 86 87 73





8/24/2012



8/24/2012

GROUP 3




PATIENT JANE DOE Tel: (404) 404-4040 DoB: 8/24/1991 Age: 20

ORDERING PHYSICIAN DEMO Doctor NPI: 0000000000 Fax: (734) 843-7718


RE: Pulse-Oximetry Test Results Attached -- Report #1794281 - Oxygen Qualification Status[1] : - Patient tested "On Oxygen" and therefore Oxygen Qualification Status may not be applicable to this report. Refer to test results and consult with HME respiratory provider as appropriate. Note: Test statistics fell under Medicare Group 3 - May not qualify for Oxygen. Reference Medicare Policy [1] - Prefer a single page report? You can now choose to receive only the summary page (page 1) of IDS pulse-oximetry reports! This page contains the most commonly used data as well as all necessary data to calculate O2 qualification per CMS guidelines. If you choose this option, IDS will continue to generate the full report and keep it on file, available upon request. To enable this feature for future studies, simply initial here and fax back to IDS at 888-771-5146. - FAX SINGLE PAGE REPORTS - PHYSICIAN INITIAL HERE: _______

Alert:Upload performed in 'DEMO' mode. Some errors will treated as warnings. Alert:Device - Oximetry test started before prescription created

CONFIDENTIALITY NOTICE: This fax is intended for the sole use of the individual(s) to whom it is addressed, and may contain information that is privileged, confidential, and exempt from disclosure under applicable law. You are hereby notified that any dissemination, duplication, or distribution of this transmission by someone other than the intended addressee or its designated agent is strictly prohibited. If you receive this fax in error, please notify IDS immediately at 1-800-355-0691. FOOTNOTES: [1] Oxygen Qualifcation Status Disclaimer and Definitions: Disclaimer: The auto-generated Oxygen Qualification statements in this report are NOT intended to diagnose any disease, determine the medical need for Oxygen, or determine final Medicare and/or insurance coverage for oxygen therapy or any other treatment. Physicians must carefully review the oximetry data, clinical information, and comorbid illnesses in conjunction with allcurrent Medicare criteria to determine if the patient should receive oxygen therapy. Definitions: Group 1, Method 1: Initial O2 Coverage for 1 year; Spo2 must be at or below 88% for 5 total minutes during sleep. Method 2:- Spo2 must fall 5% below the overall mean for 5 minutes (requires 2hrs data + signs and symptoms attributable to Hypoxemia). Group 2: Initial O2 Coverage for 3 months; SpO2 must be at or below 89% for 5 total minutes during sleep. Also requires one of the following: 1. Dependent edema sugg of CHF 2. Pulm. hypertension or cor pulmonale 3. Erythrocythemia (hematocrit > 56). Group 3: No Oxygen Coverage. Spo2 didn't meet coverage criteria. [2] Explanation of Excluded Data and Artifact: As this test is intended to be recorded while the patient is asleep, the first 5 minutes and last one minute of each recording session are assumed to be "wake" time and are excluded from calculations unless otherwise specified. Artifact is defined as: Spo2 <40; Spo2 >100; Pulse <0 or Pulse > 220 and excluded from calculations in this report. Pulse-Oximeters have built-in algorithms to identify motion artifact within the recording. Data points identified as such are excluded from IDS reports as well. [3] Explanation of Awake or Wake Statistics: Because wake/sleep state cannot be determined in unattended pulse-oximetry, "Wake" statistics are derived from the first 5 minutes of test data when it is assumed the patient is awake (using only the first session in chronological order when multiple sessions are present[6]). This same 5 minutes of 'wake' data is excluded[2] from the remainder of stats in the test report. [4] 4% Desaturation Events: Events where SpO2 falls by at least 4 percentage points from any peak saturation level within a 2 minute window (i.e. a drop from 99% to 95% within a 2 minute period would be a 4% desat event). The event's duration ends when the saturation level makes an upward movement, or when invalid or artifact data is encountered. *Events with duration of over 3 minutes are excluded. [5] Deep Desaturation Events: Events where oxygen saturations levels fell deeply - by more than 5% - within a 2 minute window from any peak saturation level (i.e. a drop from 99% to 93% within a 2 minute period will be listed here as a deep desat event). The events end when the saturation level makes an upward movement or invalid/artifact data is encountered. Events with duration over 3 minutes are excluded. [6] Sessions: A single study may be made up of multiple "sessions" from a single pulse-oximeter. A session begins each time the pulse-oximeter is powered on, and ends any time the oximeter is powered off (intentionally or unintentionally).


8/24/2012




PULSE-OXIMETRY REPORT #1794281: Nocturnal test performed while on oxygen at 2.0 LPM.

PATIENT JANE DOE 1316 COMMERCE DR DECATUR, AL 35601-7539 Tel: (404) 404-4040 DoB: 8/24/1991 Age: 20

ORDERING PHYSICIAN DEMO Doctor NPI: 0000000000 Fax: (734) 843-7718 INSURANCE: Security Blue


Start: 8/23/2012 11:59 PM - End: 8/24/2012 7:38 AM - Duration: 06:50:00 - Excluded[2]: 00:30:16 - Total Valid: 06:19:44




PULSE SUMMARY

High : 133 Low : 29



Patient tested "On Oxygen" and therefore Oxygen Qualification Status may not be applicable to this report. Refer to test results and consult with HME respiratory provider as appropriate. Note: Test statistics fell under Medicare Group 3 - May not qualify for Oxygen. Reference Medicare Policy [1] Insurance on file: Security Blue

Oximeter: WRIST3150, Serial #12341245, Uploaded: 8/24/2012 3:43:00 PM; Ax-2.0.8- WIN32, IDS-2.1.2010.01.13, Rpt-08/24/2012


8/24/2012


SPO2 Histogram


80 00:00:12 93 00:00:08 98 04:32:4084 00:00:04 94 00:00:20 99 01:33:2490 00:00:04 95 00:00:48 100 00:01:5291 00:00:12 96 00:02:08 Artifact 00:30:1692 00:00:04 97 00:07:48

Sessions [6]

SESSION NUMBER :: 001 of 2 for Rpt# 1794281 - JANE DOEStart : 8/23/2012 11:59 PM High Pulse : 133 High SpO2 : 100



SESSION NUMBER :: 002 of 2 for Rpt# 1794281 - JANE DOEStart : 8/24/2012 5:26 AM High Pulse : 117 High SpO2 : 100




8/24/2012



- 4% Oxygen Desaturation Index (ODI): 1.422 events per hour - Total Events: 9 - Average Event Duration: 17.333(seconds)




Lists events where Spo2 fell by more than 5% within 2 minute window. These events are marked on graphs by id#. ID Start End Duration SPO2 Onset SPO2 Low Pulse High Pulse Low1 12:07:29 AM 12:07:45 AM 00:00:16 99 93 109 1092 12:20:33 AM 12:21:45 AM 00:01:12 100 94 119 1083 4:06:33 AM 4:06:49 AM 00:00:16 99 92 98 864 6:23:15 AM 6:23:27 AM 00:00:12 98 90 107 101





8/24/2012



8/24/2012

group 1 - instant diagnostic · re: pulse-oximetry ... oxygen under medicare group 1 criteria...

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