Pulse Oximetry Test: Summary Report
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1 Test Condition : Overnight on Room Air Pulse Oximetry Test: Summary Report Patient Information Referring/Ordering Physician DME/HME Courier John Sample Insurance ID : B DOB : 1/1/1909 Gender : Male Pt. Report ID : Start Time : 7/24/ :29:23 PM John Pepper NPI # : Address : 1234 Main Street Phone : Fax : End Time : 7/25/2012 7:22:15 AM HME Demo Account Rester Drive NPI # : Phone : Fax : Study Date : 7/24/2012 Start Time : 11:29:23 PM End Time : 7:22:15 AM Test Duration : 07:52:52 Excluded Time : 00:10:40 Valid Time : 07:43:12 Oximeter SN : Device Type:920 Stan. R/N Testing Condition : Overnight on Room Diagnosis : COPD Diagnosis2 : Diagnosis3 : Scheduled Date : 7/24/ :00:00 AM Upload Date: 7/25/ :52:38 AM Tech Edit Date: 7/25/ :53:53 AM Highest SpO2 : 98% Average SPO2 : 89 % Lowest SpO2 : 77% Highest Pulse : 79 BPM Average Pulse : 53 BPM Lowest Pulse : 33 BPM SpO2 88 % : 03:38:12 SpO2 5% Protocol : 01:42:48 SpO2 89 % : 04:46:36 Group1 Qualifiers Group 1 Qualifier (5% Rule) Group 2 Qualifiers Group 1: Patient demonstrates saturation levels at or below 88% for five minutes or greater, taken during sleep, or a decrease in arterial oxygen saturation greater than 5% for at least five minutes, taken during sleep, with associated symptoms. Contact your local Medicare Contractor for more specifics on these diagnosis codes that support medical necessity. Respiratory Assist Device (RAD): Sleep Oximetry demonstrates oxygen saturation 88% for five minutes cumulative of nocturnal recording time (minimum recording time of two hours) while breathing oxygen at 2 LPM or current prescribed FIO2, whichever is greater. If the patient meets Group 1 Qualifier and satisfies the above test condition, this patient is a potential candidate. Check Local Guidelines Longest Continuous Recording : 00:35:56 Number of Continuous Events > 5 Minutes : 9 Oxygen Destauration Index(ODI) : A desaturation event occurs when there is a 4% points or greater drop in oxygen saturation, within a three minute window of onset. The Oxygen Desaturation Index (ODI) is calculated by the total number of desaturation events and dividing them by the valid time. Events Per Hour (ODI) : 4.45 Total Desaturations (Entire Test): 35 Excluded Artifacts : 145 Patients with an ODI of 5 or more per hour should be evaluated for sleep apnea if your clinical judgment points in that direction. Two options are an In-Lab Facility or Home Sleep Testing through Advanced Diagnostic Solutions. Independent Diagnostic Testing Facility (IDTF) Page 1 of 6
2 Test Condition : Overnight on Room Air Start Time : 7/24/ :29:23 PM End Time : 7/25/2012 7:22:15 AM Nocturnal Pulse Oximetry: SPO2 and Heart Rate Graphs Page Independent Diagnostic Testing Facility (IDTF) Page 2 of 6
3 Test Condition : Overnight on Room Air Start Time : 7/24/ :29:23 PM End Time : 7/25/2012 7:22:15 AM Independent Diagnostic Testing Facility (IDTF) Page 3 of 6
4 Test Condition : Overnight on Room Air Start Time : 7/24/ :29:23 PM End Time : 7/25/2012 7:22:15 AM Nocturnal Pulse Oximetry: Destauration Events Page D E S A T Destaturation Event : This type of event is defined when a patient s arterial oxygen saturation drops four percentage points or more within a three minute window of onset. This type of event ends when the arterial oxygen saturation moves up one percentage point or more and when there is missing, artifact or invalid data that is encountered during the desaturation event. The top 35 Desaturation Events are listed below. Excluded Artifacts : 145 Total Destaurations (Entire Test) : 35 Events Per Hour : 4.45 ID Start Time End Time Duration SPO2 Onset SPO2 Low Pulse Low Pulse High 1 11:29:23 PM 11:30:28 PM 1: :39:45 PM 11:42:03 PM 2: :42:20 PM 11:43:43 PM 1: :47:31 PM 11:49:15 PM 1: :50:07 PM 11:51:50 PM 1: :57:53 PM 11:58:45 PM 0: :03:04 AM 12:03:15 AM 0: :05:40 AM 12:06:39 AM 0: :08:15 AM 12:09:38 AM 1: :28:59 AM 12:30:47 AM 1: :41:57 AM 12:42:35 AM 0: :02:41 AM 1:03:23 AM 0: :05:17 AM 1:05:27 AM 0: :07:52 AM 1:09:08 AM 1: :15:39 AM 1:16:10 AM 0: :18:14 AM 1:18:56 AM 0: :33:47 AM 1:34:08 AM 0: :41:34 AM 1:43:04 AM 1: :54:32 AM 1:54:42 AM 0: :02:18 AM 2:02:42 AM 0: :17:51 AM 2:19:49 AM 1: :36:00 AM 2:38:29 AM 2: :38:35 AM 2:40:12 AM 1: :41:11 AM 2:41:18 AM 0: :46:22 AM 2:46:36 AM 0: :51:33 AM 2:52:59 AM 1: :07:06 AM 3:07:34 AM 0: :12:17 AM 3:14:46 AM 2: :14:53 AM 3:15:13 AM 0: Independent Diagnostic Testing Facility (IDTF) Page 4 of 6
5 Test Condition : Overnight on Room Air Start Time : 7/24/ :29:23 PM End Time : 7/25/2012 7:22:15 AM 30 4:17:05 AM 4:18:25 AM 1: :11:31 AM 5:13:46 AM 2: :21:53 AM 5:23:51 AM 1: :24:29 AM 5:25:07 AM 0: :29:40 AM 5:29:47 AM 0: :58:11 AM 5:59:27 AM 1: Independent Diagnostic Testing Facility (IDTF) Page 5 of 6
6 Test Condition : Overnight on Room Air Start Time : 7/24/ :29:23 PM Pulse Oximetry Test: SpO2 & Pulse Breakdown End Time : 7/25/2012 7:22:15 AM Percentage of Time Spent Page : This page will show a breakdown of the Pulse Oximetry Test at the individual SpO2 percentages from 99% - 40%. SPO2 : 90 SPO2 : 91 SPO2 : 92 SPO2 : 93 SPO2 : 94 SPO2 : 95 SPO2 : 96 SPO2 : 97 SPO2 : 98 SPO2 : 99 Total 90'S 9.77 % time 7.7 % time 6.81 % time 8.1 % time 3.28 % time 1.58 % time 0.46 % time 0.26 % time 0.16 % time % time SPO2 : 80 SPO2 : 81 SPO2 : 82 SPO2 : 83 SPO2 : 84 SPO2 : 85 SPO2 : 86 SPO2 : 87 SPO2 : 88 SPO2 : 89 Total 80'S 0.79 % time 1.37 % time 2.12 % time 1.73 % time 3.38 % time 5.41 % time 6.17 % time 7.4 % time % time % time % time SPO2 : 70 SPO2 : 71 SPO2 : 72 SPO2 : 73 SPO2 : 74 SPO2 : 75 SPO2 : 76 SPO2 : 77 SPO2 : 78 SPO2 : 79 Total 70'S 0.5 % time 0.94 % time 0.91 % time 2.35 % time SPO2 : 60 SPO2 : 61 SPO2 : 62 SPO2 : 63 SPO2 : 64 SPO2 : 65 SPO2 : 66 SPO2 : 67 SPO2 : 68 SPO2 : 69 Total 60'S 0 % time SPO2 : 50 SPO2 : 51 SPO2 : 52 SPO2 : 53 SPO2 : 54 SPO2 : 55 SPO2 : 56 SPO2 : 57 SPO2 : 58 SPO2 : 59 Total 50'S 0 % time SPO2 : 40 SPO2 : 41 SPO2 : 42 SPO2 : 43 SPO2 : 44 SPO2 : 45 SPO2 : 46 SPO2 : 47 SPO2 : 48 SPO2 : 49 Total 40'S 0 % time SpO2 Time Breakdown SpO2 Time <90% : 04:46:36 SpO2 Time 90% : SpO2 Time <80% : SpO2 Time <70% : SpO2 Time <60% : 00:10:52 00:00:00 00:00:00 SpO2 Time 80% & <90% : SpO2 Time 70% & <80% : SpO2 Time 60% & <70% : 02:56:36 04:35:44 00:10:52 00:00:00 Pulse Percentage Breakdown Pulse Range > 199 Pulse Range Pulse Range Pulse Range Pulse Range Pulse Range Pulse Range Pulse Range Pulse Range Pulse Range Pulse Range Pulse Range < % % % 3.17 % Independent Diagnostic Testing Facility (IDTF) Page 6 of 6
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