# Reimbursement for Pulse - Does anyone



## AR2728

Does anyone have success being paid for Pulse Oximetry 94760 or 94761 when done in conjunction with an E&M?   We have never billed this as a separate service, always considered it an integral part of the E&M.  However, our pulmonologist is requesting an additional pulse oximeter and management wants to know if there is any way to receive payment since the patient is "walked around" for a while before testing.


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## tsnider

Hi there,

We do bill the pulse oximetry codes (either 94760 or 94761), unfortunately some payers require a -25 on the E/M codes and may even want a -59 on the pulse ox code.

That is our experience, hope that helps!


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## AR2728

Thanks for the information.  I'm sure we would get past the edits by adding the modifiers, I'm just not sure their documentation justifies billing the pulse ox in addition to the E&M.  They have very little information other than what the pulse ox reading was.


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## airart

*Article on Ox Readings with an E&M charge*

Found this article for you, hope it helps.  Maybe you could get them to document at least the medical necessary reasons below that apply to that patient.

Oximetry Services CPT code 94760, 94761, 94762 
Oximetry measures oxygen saturation using a non-invasive probe. This is done by measuring light absorption of oxygenated hemoglobin and total hemoglobin in arterial blood.

Medicare will allow payment for oximetry when accompanied by an appropriate ICD-9-CM code for a pulmonary disease(s) which is commonly associated with oxygen desaturation. Routine use of oximetry is non-covered.

Medically necessary reasons for pulse oximetry include:

1.) Patient exhibits signs or symptoms of acute respiratory dysfunction such as: 
o	Tachypnea.
o	Dyspnea.
o	Cyanosis.
o	Respiratory distress.
o	Confusion.
o	Hypoxia.

2.) Patient has chronic lung disease, severe cardiopulmonary disease or neuromuscular disease involving the muscles of respiration, and oximetry is needed for at least one of the following reasons: 

o	Initial evaluation to determine the severity of respiratory impairment.
o	Evaluation of an acute change in condition.
o	Evaluation of exercise tolerance in a patient with respiratory disease.
o	Evaluation to establish medical necessity of oxygen therapeutic regimen.

3.) Patient has sustained severe multiple trauma or complains of acute severe chest pain.

4.) Patient is under treatment with a medication with known pulmonary toxicity, and oximetry is medically necessary to monitor for potential adverse effects of therapy.

These services may be performed in the home or office by a provider or by an independent diagnostic testing facility.

The results of tests performed by a durable medical equipment supplier to qualify patients for home oxygen service are not covered.

Overnight Oximetry (94762) is considered medically necessary when performed for any of the following circumstances:

•	The patient has a condition for which intermittent arterial blood gas sampling is likely to miss important variations.
•	The patient has a condition resulting in hypoxemia and there is a need to assess supplemental oxygen requirements and/or a therapeutic regimen.
Compliance with the provisions in this LCD may be subject to monitoring by postpayment data analysis and subsequent medical review.

LCD Individual Consideration
Additional payment may be allowed for oximetric determinations exceeding the parameters described in the â€œUtilization Guidelinesâ€� section below on an â€œindividual considerationâ€� basis. The â€œLCD Individual Considerationâ€� procedure is described in the related Article.

Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

•	Safe and effective.
•	Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
•	Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is: 
o	Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member.
o	Furnished in a setting appropriate to the patient's medical needs and condition.
o	Ordered and furnished by qualified personnel.
o	One that meets, but does not exceed, the patient's medical need.
o	At least as beneficial as an existing and available medically appropriate alternative.

Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12X, 13X, 18X, 21X, 22X, 23X, 71X, 73X, 74X, 75X, 77X, 85X
Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X is effective for dates of service on or after April 1, 2010.

Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. 

Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance.
046X, 0410, 0412 and 0419

CPT/HCPCS Codes

Note:	Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
94760Â©	Measure blood oxygen level
94761Â©	Measure blood oxygen level
94762Â©	Measure blood oxygen level

ICD-9-CM Codes That Support Medical Necessity

The CPT/HCPCS codes included in this LCD will be subjected to â€œprocedure to diagnosisâ€� editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

(Link: http://www.medicarepaymentandreimbursement.com/2011/09/oximetry-services-cpt-code-94760-94761.html)


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## kathie e

*e/m audit*

i have a question about pulse ox 94760 im trying to dtermined data amount and complexity under the 1995 guidelines for e/m coding at emergency visit hispital setting could this code be considered a point extra such as lab or test please advice thanks


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## Delphi

*Pulse ox rev code & VA billing*

I have found rev code 0460 for puls ox 94760 hcpc code for Va, billing is following MCR standards, the clinc code is G0463 instead of the hcpc.
this helped for the pulmonary clinic I was billing, facility portion.
NO modifiers. With this the claim was paid. HOpe this helps.


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## TiffianyEdwards

*94761*

Does anyone have any new info on billing 94761 and EM codes I am in Wy and Noridian is telling me it's a Status T code, which is bundled. However, that being said we are doing the Pulse Ox as a separate procedure secondary to the EM visit. The patients are on O2 and are required to be re-certified, so they are being walked up and down the hall way and the desats are being recorded as part of the documentation the dr fills out for the DME re cert ??


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## Bjohnse1

As a payer I routinely deny billings of 94760 when billed with E/M codes. We see it as more as obtaining a vital sign (BP/pulse/temp/O2 stats) rather than a test. But if it is being done as a Dx test instead of routine part of the exam you shouldn't have an issue getting paid. If it is being denied you can always call the insurance company and explain your resoning.


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## MarissaCruz

*6 minute walk*

Are you referring to a 6 minute walk?? 94620


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## CodingKing

I wouldn't put 59 on something just because it bypasses edits. That open you up to sanctions. The carrier I work for does not pay separately for this.


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## pedscoder21

We are having this issue, too. Even with 25 on the E/M, it isn't being paid. I don't think applying an XU is warranted just to bypass an edit. Per MedAssets, the only modifier permitted when billing for those two codes would be a modifier on the E/M (25). Frustrating!


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## CodingKing

pedscoder21 said:


> We are having this issue, too. Even with 25 on the E/M, it isn't being paid. I don't think applying an XU is warranted just to bypass an edit. Per MedAssets, the only modifier permitted when billing for those two codes would be a modifier on the E/M (25). Frustrating!



Its not being paid because its bundling in the office visit. really it takes less time, effort or skill then routine phlebotomy


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