ED Coding and Reimbursement Alert

Question: A patient with a diagnosed history of sleep apnea reports to the ED complaining of an exacerbation of his condition. The nonphysician practitioner (NPP) performs history and examination, and then performs pulse oximetry. The physician then interprets the oximetry results, instructs the patient to follow up with his pulmonologist, and sends him home. I was going to report an ED E/M and 97560 for the oximetry interpretation. A fellow coder told me that oximetry interpretation is not a billable ED service, so I am hesitating. How should I code this scenario?

Texas Subscriber

Answer: Both Medicare and CPT have literature indicating that you should not report pulse oximetry interpretation services in the ED. On the claim, report the following:

• The appropriate level ED E/M code based on encounter notes. Your encounter resembles a 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of moderate complexity ...), but be sure to check your notes to get an exact read on the level.
• 327.23 (Organic disorder of excessive somnolence [Organic hypersomnia]; Organic sleep apnea; Obstructive sleep apnea [adult] [pediatric]) appended to the ED E/M code to represent the patient's sleep apnea.

Explanation: Medicare payers agree that pulse oximetry interpretation lacks significant physician work value; consequently, there are no relative value units (RVU) or payment amounts for these codes, and no Medicare payer will reimburse separately for pulse oximetry interpretation.

CPT also has guidance against coding pulse oximetry interpretation separately. As CPT Information Services states: "From a CPT Coding perspective, the purpose of codes 94760 and 94762 is to identify that the physician owns the equipment used for the oximetry and performed the interpretation of the results. ... 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."