Primary Care 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. But Medicare and Medicaid deny the $18 pulse oximetry charge and only pay me the $17 for the office visit. How can I stop losing money?

Texas Subscriber
 
Answer: Unfortunately, Medicare will not pay for pulse oximetry, such as 94760 (Noninvasive ear or pulse oximetry for oxygen saturation; single determination), in addition to an office visit (99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient). The National Medicare Physician Fee Schedule classifies 94760 and 94761 (... multiple determinations [e.g., during exercise]) as "status T." That means Medicare includes pulse oximetry payment in the allowance for any services that the physician provides on the same day. Medicare bases the inclusion on the grounds that recording pulse oximetry is no different from recording the patient's temperature or other vital signs, which you may not separately report.
 
Some private insurers may cover 94760-94761 with 99201-99215 as long as pulse oximetry is reasonable and medically necessary. For instance, you can separately report pulse oximetry when you perform the test to make a diagnosis or to assist with medical decision-making.   

You may need to send the insurer a copy of CPT's note stating that 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.