ED Coding and Reimbursement Alert

If you bill for the interpretation of pulse oximetry and your hospital owns the equipment, append the pulse oximetry code with modifier -26 (Professional component).

For some payers, pulse oximetry can be a separately identifiable service, so don't automatically bundle it into other service codes.

You can separately bill pulse oximetry when it's done for the purposes of making a diagnosis or assisting with medical decision-making in relationship to the chief complaint, says Jan Loomis, director of coding and documentation at TeamHealth West in Pleasanton, Calif. A patient with asthma is a good example of this, she says. On the other hand, oximetry for a patient with a sprained ankle would likely be considered a routine vital and should not be billed, she adds.

For most payers, to bill pulse oximetry separately, the test must go beyond routine testing and the recording of a numerical result. It is the physician's interpretation of the numerical result that contributes to the patient's care plans, says Mike Ganovsky, MD, CPC, CFO, of Greater Washington Emergency in suburban Maryland.

Though you're allowed to bill for this interpretation, it is still prudent to "tread lightly" when it comes to reporting pulse oximetry as a separate service, says Robert La Fleur, MD, FACEP, president of Medical Management Specialists. "In this day and age, pulse oximetries are done almost like a vital sign," he says. Consider whether the physician's interpretation of pulse oximetry warrants a separate charge any more than his interpretations of pulse, blood pressure, and temperature do, La Fleur says. Some payers may pay separately for pulse oximetry interpretation, but just because you can bill for it doesn't mean you should, he adds.

Lean documentation for pulse oximetry is a surefire way not to get paid.

When medical necessity justifies separate payment, it must be clearly documented in order for the service to be coded, says Maria Narvaez, RHIT, a coding consultant in Pennsylvania for National Health Systems. Most insurers require a note by the physician, adds Todd Thomas, CPC, CCS-P, president of Thomas & Associates, a company ensuring reimbursement for emergency physicians in Oklahoma City. According to Thomas, documentation for pulse oximetry interpretation should include:

A reference made to triage vitals and documentation from the nursing notes do not qualify as sufficient interpretation, he says.

Because of Medicare's stingy policy on pulse oximetry, most coders skip billing it, but Medicare may not be as miserly as you think.

Don't automatically assume that billing for pulse oximetry precludes separate payment from Medicare. You can bill for pulse oximetry if it was performed alone. According to CMS policy on T-status codes, which include 94760 and 94761, "If the status-T service is performed by itself it will be considered for payment." Unfortunately, this scenario is uncommon in the ED where an E/M or procedure code related to the visit usually takes precedence.

You can, however, bill a pulse oximetry in addition to other services provided by the same provider on the same date, if the additional procedures are not payable under the Physician Fee Schedule. According to CMS, only if the T-status (i.e., pulse oximetry) procedure is performed on the same day as another Medicare Physician Fee Schedule service will it be "denied as bundled."

But given this prohibition, watch out for those E/M codes. Even though CPT states that you can assign pulse oximetry codes in addition to an E/M service (e.g., 99283, ED visit ...), you won't get paid by Medicare, which bundles the oximetry into the E/M service, Loomis says. As always, be aware that submitting a code that you know Medicare won't pay can lead to compliance problems if it is paid by accident.

Despite these rules, some carriers do pay for pulse oximetry as a separately identifiable service even with other codes, as long as the test was medically necessary. Pulse oximetry may be medically necessary to evaluate conditions including oxygen desaturation, dyspnea, cyanosis, tachypnea, chest pain, asthma, pneumonia, bronchitis, patients with chronic lung disease, and others, Narvaez says.

Remember, though, that checking your local carrier's policy is imperative for this payer-dependent set of codes. Pay special attention to this familiar advice for pulse oximetry.