Pediatric Coding Alert

Question: What can I do about payers bundling pulse oximetry with office visits? I often perform pulse oximetry on newborns to determine a definitive diagnosis, such as broncholitis or respiratory syncytial virus (RSV). But Texas Medicaid denies the $18 pulse oximetry charge and  pays me only the $17 for the office visit. My pediatric friends in Georgia, however, get Medicaid payment for the service and the procedure. How can I stop losing money? Can I at least bill for the single-use probe?

Texas Subscriber

Answer: Each state has its own Medicaid regulations. So, Texas Medicaid may reject pulse oximetry (94760, Noninvasive ear or pulse oximetry for oxygen saturation; single determination) with an office visit (99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient), and Georgia Medicaid may not.

Most carriers, however, follow CMS documentation and billing guidelines. In 2000, the agency stated that pulse oximetry is no longer a separate procedure. As such, Medicare bundles the procedure into a same-day higher service, such as an office visit or pulmonary spirometry. For the payers that implemented this rule, you should write off the charge before it goes out the door. Make sure to keep the code on your superbill and put it on the claim form as well.

Some private insurers may still cover 94760 with 99201-99215 as long as pulse oximetry is reasonable and medically necessary. For instance, as in your examples, you can separately report pulse oximetry when you perform the test to make a diagnosis or to assist with medical decision-making.

You may also need to send the insurer a copy of CPT's note that states the levels of E/M services don't include the actual performance and/or interpretation of diagnostic tests/studies that a physician orders during a patient encounter. You may separately report physician performance of diagnostic tests/studies for which specific CPT codes are available, according to CPT.

For the oxygen probe, you may report A4606 (Oxygen probe for use with oximeter device, replacement). Texas Medicare indicates that you should bill the durable medical equipment regional carrier, Palmetto GBA, for the supply.