Pediatric Coding Alert

As of this month, Medicare will no longer pay for pulse oximetry (94760, 94761, 94762) billed with other procedures, and experts expect commercial insurance companies will eventually follow suit.

This means that if you bill any other code on that day, you cannot bill pulse oximetry as well: Medicare has bundled the oximetry codes into every other CPT Codes . If you perform pulse oximetry and nothing else, that is the only time you could bill and get paid for this procedure. Various state Medicaid programs probably will stop paying for these codes this year. How should you respond?

The answer is: keep billing for pulse oximetryas long as you can. I plan to continue using it as its designed, as a procedure that requires work outside of the evaluation and management (E/M) codes, says Richard H. Tuck, MD, FAAP, of Primecare Pediatricians in Zanesville, Ohio, and founding chair of the American Academy of Pediatricians (AAP) committee on coding and reimbursement. Medicare has chosen to bundle it. But that doesnt accurately reflect the CPT system.

Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant based in S.C., agrees. Until they hear otherwise from the commercial carriers, pediatricians can still use these codes, she says. But be forewarned, a lot of carriers will jump on the bandwagon.

Eventually they all will bundle it, says Curtis Udell, CPAR, CPC, president of Emphysys, a physician reimbursement and compliance consultant based in Cumming, Ga. Most insurance companies do follow what Medicare does, he adds. But until then, pediatricians should continue to go ahead and bill it.

Judith Wise, CPC, internal auditor for West Virginia University Hospital in Morgantown (and formerly the manager of the pediatrics department there), notes that just because something is a bundled code for Medicare, that doesnt mean its bundled for commercial plans.

You should bill it for everyone, she says. You cant switch your billing methods for different payers. But, she says, once you know that a commercial payer is bundling the code, you need to write it off before it goes out the door. Nevertheless, you need to keep the code on your superbills and put it on the claim form as well.

Why did Medicare make this move? It views pulse oximetry as similar to taking a patients temperature. Pulse oximetry is no more invasive and arguably less invasive than recording the patients temperature, another example of a diagnostic service for which we do not make separate payment, says the Nov. 2, 1999, Federal Register notice announcing the coverage decision. If interpretation of pulse oximetry or temperature data is complex, then that interpretation is clearly part of the medical decision-making included in the E/M services, the notice continues. Pulse oximetry is routine in many visits, the notice adds. And finally, Medicare says that the equipment is paid for by facility and practice expense payments.