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Pulmonology Coding Alert

Separate Pulse Oximetry Can Get Paid Heres How

Published on Sun Jun 01, 2003

Do you automatically write off pulse oximetries? If so, you could be losing out on reimbursement. Some payers reimburse pulse oximetry if it's a separately identifiable service, so don't automatically bundle it into other services or procedures.

Pulse oximetry is a noninvasive measurement of oxygen saturation of hemoglobin in arterial blood stated as a percentage, says Antoinette Revel, CPC, a coding expert and nurse practitioner working at Healthcare Consulting Services in Warrington, Pa. The codes for pulse oximetry are:

  • 94760 Noninvasive ear or pulse oximetry for oxygen saturation; single determination
  • 94761 ... multiple determinations (e.g., during exercise)
  • 94762 ... by continuous overnight monitoring (separate procedure).

    Pulmonologists will use pulse oximetry on critically ill patients with pulmonary problems, she says. The pulse oximetry allows for continuous monitoring of intrapulmonary shunts and the adjustments of oxygen and positive pressure without using arterial blood gas, an invasive procedure. Asudden change in the pulse oximetry reading may serve as an early warning of an alteration in a patient's oxygen intake and need for immediate assessment just in case, for example, secretions have obstructed a patient's airway or a ventilator has been accidentally disconnected, she says.

    Pulse oximetry may be medically necessary to evaluate conditions including asthma, pneumonia, bronchitis, and patients with chronic lung disease, in addition to other conditions.

    Most coders include the work done from pulse oximetry in the appropriate E/M code for the visit, which is accurate. In certain circumstances, however, you can separately report pulse oximetry codes as an outpatient service. The hospital covers it when done in a facility.

    When You Can Report Pulse Oximetry, Use Caution

    Report pulse oximetry when it is reasonable and medically necessary, Revel says.

    You can separately report pulse oximetry when it's done for making a diagnosis or assisting with medical decision-making in relationship to the chief complaint, says Jan Loomis, director of coding and documentation at TeamHealth West in Pleasanton, Calif. Pulse oximetries of a patient with asthma would be a good example of when this happens, she says.

    For most payers, however, to separately report pulse oximetry, the test must go beyond routine testing and the recording of a numerical result. It is the physician's interpretation of the numerical result that contributes to the patient's care plans, says Mike Ganovsky, MD, CPC, CFO.

    Although you're allowed to bill for this interpretation, you should "tread lightly" when it comes to reporting pulse oximetry as a separate service, says Robert La Fleur, MD, FACEP, president of Medical Management Specialists. "In this day and age, pulse oximetries are done almost like a vital sign," he says. Consider whether the physician's interpretation of pulse oximetry warrants a separate charge any more than his interpretations of pulse, blood pressure and temperature do, La Fleur argues. Some payers may pay separately for pulse oximetry interpretation, but just because you can bill for it, doesn't mean you should, he says.

    Documentation From Physician Required

    Lean documentation for pulse oximetry is a surefire way not to get paid. When medical necessity justifies separate payment, it must be clearly documented for you to code the service, says Maria Narvaez, RHIT, a coding consultant in Pennsylvania for National Health Systems.

    Most insurers require a note by the physician, adds Todd Thomas, CPC, CCS-P, president of Thomas & Associates in Oklahoma City. According to Thomas, your documentation for pulse oximetry interpretation should include:

  • a percentage
  • what the percentage is related to (for example, within normal limits, low normal)
  • whether the patient was on oxygen or room air
  • plan of action for abnormal findings.

    A reference made to triage vitals and documentation from the nursing notes does not qualify as sufficient interpretation, he says.

    Check Payer Stipulations

    Payment for pulse oximetry varies widely from payer to payer, so pay close attention to policy differences to avoid denials and collect separate payment when payers do cover it.

    Contact your 10 primary payers and ask them to submit, in writing, their policies on reporting and paying for pulse oximetry, Revel says.

    Remember to check the National Corrective Coding Initiative (NCCI) edits when reporting to any payer. NCCI edits bundle pulse oximetry into critical care services (99291-99296) and subsequent intensive care for low birth weight (99298-99299), but not other E/M services, Revel says. NCCI also bundles it into 94620 (Pulmonary stress testing; simple) and anesthesia services, she adds.

    Pay Special Attention to Medicare

    Don't automatically assume that billing for pulse oximetry precludes separate payment from Medicare.

    You can bill for pulse oximetry if it is the only service the physician performs. According to CMS policy on T-status codes, which include 94760 and 94761: "If the status-T service is performed by itself it will be considered for payment." You can also bill pulse oximetry in addition to other services provided by the same provider on the same date if the additional procedures are not payable under the Physician Fee Schedule. According to CMS, only if the T-status (i.e., pulse oximetry) procedure is performed on the same day as another Medicare Physician Fee Schedule service will it be "denied as bundled."

    Watch out for those E/M codes when reporting to any Medicare carrier. Even though CPT suggests that you can assign pulse oximetry codes in addition to an E/M service, Medicare won't pay for both, Loomis warns. As always, be aware that submitting a code that you know Medicare won't pay can lead to compliance problems if the carrier pays by accident.

    Check your local medical review policies (LMRPs) because they may have additional clauses that explicitly deny, in all circumstances, separate payment for 94760 and 94761. The local Medicare medical policy bulletin for Revel's area states, "Codes 94760 and 94761 are bundled on the Medicare Fee Schedule. Separate payment is not allowed for these services."

     

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