Pulmonology Coding Alert

Think coding pulse oximetry is easy because pulmonologists frequently perform this service? Think again. You should not bill it separately -- except on certain rare occasions. Otherwise, you run the risk of a denial.

Background: Medical people often call pulse oximetry the "fifth vital sign," along with blood pressure, heart rate, temperature, and respiration rate, and use it in different healthcaresettings. Pulmonologists and respiratory care specialists make good use of pulse oximetry, often using it as a component in monitoring other diagnostic studies and treatments.

The real deal remains that reporting and reimbursement of the three related pulse oximetry codes are confusing. Ask these three questions, and get your money back free of billing blues.

Yes, you can report overnight oximetry with 94762 (Noninvasive ear or pulse oximetry for oxygen saturation; by continuous overnight monitoring [separate procedure]) with other services, but make sure your practice owns the oximetry equipment, says Stephanie Efstratis, CPC, business services manager at Pulmonary Medicine Associates in Carmichael, Calif In addition, the patient must perform the overnight oximetry in a home setting.

Cost: "The code has no physician work, but has 0.62 non-facility relative value units (RVUs), which yield about $22.37 of practice expense, based on national average.

A description and interpretation of the data would be helpful to document in the chart even though there is no payment for that work," explains Alan L. Plummer, MD, professor of medicine in the Division of Pulmonary, Allergy and Critical Care at the Emory University School of Medicine in Atlanta.

Remember: "CPT 94762 is the only oximetry code that you can bill with other services," adds Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia, Pa.

Requirements: Keep in mind, however, you must meet the following requirements before Medicare will accept 94762:

• Your pulmonologist must provide a face-to-face service during the office visit (99201-99215, Office or other outpatient visit ...) in which the pulmonologist gives the patient the oximetry equipment.
• At the time of the visit, the pulmonologist should instruct the patient on equipment use. He must also answer any patient questions. This direct encounter allows the pulmonologist to assess the patient's comprehension and physical ability to carry out the instructions.
• The medical record must document that the oximeter is self-sealed and cannot be adjusted by the patient. "The oximeter must meet the standard requirements of being able to measure data without being patient-dependent," Pohlig notes. "The patient should be unable to tamper with the device."
• The device must allow for a printout that documents an adequate number of sampling hours (a minimum of four hours should be recorded), percent of oxygen saturation, and an aggregate of the results.

Remember, 94762 does not include payment for any work the physician performs but only for technical services. You can report the 94762 on the same day that the physician provides a separately identifiable E/M service (99201-99215) in which the E/M service involves more than just looking at the data from the overnight oximetry and is otherwise medically necessary.

Example: A pulmonologist orders overnight pulse oximetry for a patient with dyspnea after explaining to the patient how to use the device. The oximeter belongs to the pulmonologist. Therefore, you would report 94762 when the patient returns the overnight pulse oximetry and the physician interprets the readings.

Caution: If a testing company delivers and retrieves the oximetry device from the patient, the physician does not bill for 94762.

Medicare assigns a "T" status for 94760 (Noninvasive ear or pulse oximetry for oxygen saturation; single determination) and 94761 (Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations [e.g., during exercise]). That means payers always bundle  reimbursement for these two pulse oximetry services and include it with the payment of any other service provided on the same day.

Difference: Code 94760 is for a single reading, while 94761 is for two or more readings. For instance, if the pulmonologist's nurse takes a patient's resting pulse oximetry level, has the patient walk around, and then checks the level again while the patient is walking, you would code 94761.

Payers include 94760 and 94761 as elements of other pulmonary procedures such as a simple pulmonary stress test (94620) and respiratory therapy services (G0237, G0238, and G0239). Additionally, do not report pulse oximetry when the pulmonologist performs an office visitas the primary service on the same day.

Exception: You can report these codes for reimbursement only when the pulmonologist's staff measures either 94760 or 94761 in the office setting, and the patient receives no other service on that day. "If any  ther services payable under the physician fee schedule are billed on the same date by the same provider, these services are bundled into the physician services for which payment is made," the Addendum A of the 2010 Medicare National Physician Fee Schedule Relative Value File states.

Your Local Coverage Determinations (LCDs) tell you what a Medicare carrier will accept as medical necessity. A typical LCD published by Medicare contractors describe coverage for oximetry when accompanied by a specific ICD-9 diagnosis code.

Important: Never report what will get your claim paid. Report only what your physician documents.

Curious about what some LCDs include? Some private insurers may cover 94760-94761 with office visits as long as the reasons for medical necessity include:

• Patient shows signs of acute respiratory dysfunction such as tachypnea (786.06), dyspnea (786.09), cyanosis (782.5), respiratory distress syndrome (518.5), confusion (298.9), and hypoxia (799.02).
• Patient has chronic lung disease, severe cardiopulmonary disease, or neuromuscular disease involving the muscles of respiration, where oximetry can help with the patient's evaluation.
• Patient has sustained severe multiple trauma orcomplains of acute severe chest pain.
• Patient is under treatment with a medication with known pulmonary toxicity, where oximetry can assist in monitoring for possible adverse effects of therapy.

Smart: An ideal medical record should clearly document the reason for pulse oximetry, the frequency and the results. Check your payer to see what they require.

Nonetheless, the general scenario reveals one ugly truth for practices: most insurers follow Medicare's lead and consider 94760-94761 as bundled services. "Almost none of the managed-care organizations (MCOs) pay for pulse oximetry," says Richard Lander, MD, a national coding speaker and coding consultant in Livingston, N.J.

Pulse oximetry in hospital settings is bundled with other procedures. The device, itself, has also become quite affordable in the market, and most practices do not spend much of their time running after payers for minimal reimbursement. But the importance of oximetry lies in medical decision making (MDM), where it can influence the complexity of data under review, and thus help in the treatment of the patient.