ED Coding and Reimbursement Alert

Question: Can we bill for a pulse oximetry? I’ve heard it both ways. What about just reporting the interpretation?

Nevada subscriber

Answer: CMS does not recognize 94760 as a payable service in a facility setting. Even in an office setting it is only payable when it is the only service provided on a calendar day.

Historically, physicians providing a pulse oximetry interpretation in a setting where they did not own the equipment would report 94760 with modifier 26 to indicate that they were providing only the interpretation on the test and not the technical component. However, CPT^® and the Centers for Medicare and Medicaid Services (CMS) have addressed the issue and it is no longer appropriate to report 94760 in a hospital setting.

“The non-invasive procedure for oximetry testing either by pulse or ear, is very simple and requires little training or skill. The most commonly used testing device even produces a printed result. Assure that payment screens for this procedure are reasonable. Some carriers have established inherent reasonableness payment levels for ear and pulse oximetry in the $5 to $10 range,”

“We propose to discontinue separate payment for CPT codes 94760 and 94761...and to list them in the fee schedule with a status code of “B” for payment that is always bundled into payment for other services. Pulse oximetry is not more invasive and arguably less invasive than recording a patient’s temperature. If interpretation of pulse oximetry is complex, then that interpretation is clearly part of the medical decision making included in E/M services. We believe that payment for pulse oximetry equipment is included in our facility and practice expense payment. “, CMS says in the11/2/99 federal register for the 2000 physician fee schedule.

“From a CPT Coding perspective, the purpose of codes 94760 Noninvasive ear or pulse oximetry for oxygen saturation; single determination, and 94762 Noninvasive ear or pulse oximetry for oxygen saturation, by continuous overnight monitoring (separate procedure) is to identify that the physician owns the equipment used for the oximetry and performed the interpretation of the results.

Therefore, if the physician does not own the equipment used to perform the ear pulse oximetry, it would not be appropriate to report code 94760 or 94762 to identify his or her services. Interpretation of the ear or pulse oximetry results performed by the physician when the equipment is not owned by the physician (e.g. performed on hospital-owned equipment) is considered part of the medical decision making component of the evaluation and management (E/M) service codes.”, according to CPT^® Information Services.

There is clear documentation from American Medical Association and CMS that CPT^® code 94760 has no physician work value and cannot be reported by a physician in a facility setting.