Pulmonology Coding Alert

Question: When does Medicare allow separate payment for pulse oximetry? Which ICD-9 codes support medical necessity of this procedure in the outpatient setting?

Georgia Subscriber Answer: Medicare will pay for oximetry separately on an outpatient basis when the pulmonologist uses it to evaluate conditions that typically involve oxygen desaturation. Your pulmonologist uses oximetry to measure arterial oxygen saturation. A noninvasive probe measures light absorption of oxygenated hemoglobin and total hemoglobin in arterial blood.

Pulmonologists may bill for the service in the outpatient setting. To support medical necessity for oximetry, the patient should have signs and symptoms of acute respiratory distress, such as tachypnea (786.06), cyanosis (782.5), severe chest pain (786.50), dyspnea (786.09), hypoxia (799.0), or acute confusion (293.0), which is probably organic in nature. Your pulmonologist could also use oximetry if the patient has chronic lung disease, chest trauma, severe cardiopulmonary disease, or neuromuscular disease involving the respiratory muscles to initially evaluate the severity of the respiratory condition or to evaluate an acute change in one of these conditions. Other indications include assessing a patient's tolerance for exercise or determining whether the patient requires oxygen therapy. Medicare may also pay for oximetry to monitor for adverse effects of therapy if the patient is taking a medication known to be toxic to the lungs.

If your pulmonologist performs screening services (V codes) in the absence of signs or symptoms of desaturation or a condition that affects oxygen saturation, Medicare will not pay for the service. The CPT codes you can report for oximetry include 94760 (Noninvasive ear or pulse oximetry for oxygen saturation; single determination), 94761 ( multiple determinations [e.g., during exercise]), and 94762 ( by continuous overnight monitoring [separate procedure]).

When your physician simply checks a pulse oximetry, he should report 94760. If the evaluation requires the physician to determine the modifying factors of a decreased saturation level, such as exertion, the physician may take a baseline oximetry in addition to one while the patient is exerting himself (i.e., exercise) and bill 94761. Reporting 94762 requires the patient's oxygen saturation level to be monitored overnight. Your pulmonologist would interpret the recordings and report 94762 on the date of interpretation. Carriers will not reimburse both 94760 and 94761 if you report any other service payable under the Physician Fee Schedule on the same date.

Also, insurers consider payment for 94760 or 94761 included in the payment for the other service reported on the same date. Your physician's work involves management of the hypoxemia, which you reported as an E/M (if the physician saw the patient). If you report an E/M, you can't report pulse oximetry.

  Answers and advice for You Be the Coder and Reader Questions were provided by Carol Pohlig, BSN, RN, CPC, [...]