Pulmonology Coding Alert
Pulse Oximetry
Question: When does Medicare allow separate payment for pulse oximetry? Which ICD-9 codes support medical necessity of this procedure in the outpatient setting? Idaho Subscriber Answer: Oximetry measures arterial oxygen saturation. A noninvasive probe measures light absorption of oxygenated hemoglobin and total hemoglobin in arterial blood. Medicare will pay for oximetry separately on an outpatient basis when it is used to evaluate conditions that typically involve oxygen desaturation.
If the physician simply checks a pulse oximetry, he or she 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 94760. Reporting 94762 requires the patient's oxygen saturation level to be monitored overnight. The physician would interpret the recordings and report 94762 on the date of interpretation. Both 94760 and 94761 will not be reimbursed if any other service that is payable under the Physician Fee Schedule is reported on the same date. Payment for 94760 or 94761 is considered included in the payment for the other service reported on the same date. The physician work involves management of the hypoxemia that is captured as an E/M (if the physician sees the patient). If an E/M is reported, pulse oximetry is not.
This service is not billable by the physician for hospital inpatients. Pulmonologists may bill for the service, however, 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. Oximetry also could be used 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 also may pay for oximetry if the patient is taking a medication known to be toxic to the lungs to monitor for adverse effects of therapy.
Screening services (V codes) are performed in the absence of signs or symptoms of desaturation or a condition that affects oxygen saturation, in which case Medicare would not pay for the service.
The CPT codes used to bill for oximetry include:
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