Pulmonology Coding Alert

Hint: Oximetry is bundled into an E/M visit.

Ear or pulse oximetry is a vital procedure that can help pulmonologists identify respiratory issues. However, if you report the noninvasive procedure when you shouldn’t, your claim could receive a denial.

Pulmonology Coding Alert gathered up several oximetry frequently asked questions to provide you with essential answers.

First, Get to Know the Oximetry Test

With a noninvasive oximetry test, the physician measures the patient’s oxygen (O2) saturation by placing an oximeter on the patient’s finger or ear. The oximeter features a clip design for simple placement on the body part, and the sensor shines a light through the patient’s fingertip or earlobe to measure the amount of oxygen in the patient’s blood. The sensor detects the differences between how the oxygen-saturated blood cells and the blood cells without oxygen reflect the light. 

The CPT^® code set includes the following oximetry codes:

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

You’ll assign 94760 or 94761 for measurements captured during an in-person evaluation and management (E/M) visit, whereas 94762 is designated for continuous oximetry monitoring during an overnight session.

‘Can I Bill Oximetry as a Separate Procedure?’

The answer to this question depends on multiple factors, including when the procedure takes place and if the procedure is medically necessary.

Most important, you cannot report oximetry codes separately with an E/M code. “Codes 94760-94762 are always bundled into E/M, and the codes are considered similar to a vital sign like blood pressure, pulse, temperature, etc. In an E/M visit, ear or pulse oximetry is not separately billable,” says Dawn Toole, CPC, reviewer-coding quality II THC & specialty, of Northeast Georgia Physicians Group in Gainesville, Georgia.

“Even if the patient has an unrelated problem, such as foot pain, and has 94760 or 94761 done, the pulse ox isn’t billable as it’s bundled into the E/M,” Toole adds.

On the other hand, you may report 94762 if the pulmonologist deems the procedure is necessary for the following reasons:

• To determine an exacerbation of a respiratory condition, such as chronic obstructive pulmonary disease (COPD) or asthma;
• To assist in diagnosing a patient’s condition; or
• To assist in medical decision making (MDM) related to the chief complaint.

If the patient calls and describes an ongoing problem, the physician may order overnight oximetry and ask the patient to come into the office on the day of completion.

‘Can I Bill 94760/94761 on the Same Date of Service?’

No, you cannot bill 94760 and 94761 together on the same date of service (DOS).

Why not? You don’t have to look further than the code descriptors. Code 94760 states it is for a “single determination,” while 94761 describes “multiple determinations,” meaning you’ll assign 94760 for one ear or pulse oximetry measurement and 94761 for more than one ear or pulse oximetry measurement.

The second reason involves the status designated by the Centers for Medicare & Medicaid Services (CMS). “CPT^® codes 94760 and 94761 are status ‘T’ per CMS, which means you cannot report each code with the other code during the same visit,” Toole says.

‘Is 94762 Ever Reported Separately?’

Yes, you can report 94762 separately, but there are very specific circumstances depending on the payer.

For instance, Wisconsin Physicians Service Insurance Corporation Government Health Administrators (WPS GHA), the MAC for Indiana, Iowa, Kansas, Michigan, Missouri, and Nebraska suggests considering the following questions before submitting a claim for 94762:

• Is this the correct code for the service rendered?
• If the patient was in a facility, was the patient in the facility overnight?
• Was the patient in their home? (includes private residents, assisted living facility, etc.)
• Is there medical necessity for continuous overnight monitoring?

The location where the service takes place is important since 94762 is a “technical” code. “When patients are in a facility-based stay (e.g. inpatient, observation, or nursing facility), 94762 is not separately payable and is included in the overall payment made to the facility,” says Carol Pohlig, BSN, RN, CPC, manager of coding and education in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia.

With this helpful criteria in mind, let’s examine the following scenario to see if you can bill oximetry testing as a separate service.

Scenario: A patient with COPD is suffering from acute bronchitis and has been waking up in the morning feeling dizzy, disoriented, and experiencing a higher heart rate. The provider measures the patient’s O2 saturation in the office, and the results appear normal. The provider then orders continuous pulse oximetry monitoring overnight to review the patient’s blood oxygen levels while the patient sleeps at home. The patient is requested to return for a follow-up in 3 days, when the provider reviews the results of the pulse oximeter.

For the situation above, you can report 94762 separately. “CPT^® 94762 is considered a ‘separate’ procedure. It is usually part of a more complex service, but if the procedure is done alone or with another unrelated procedure/service, it can be reported or coded separately,” Toole says.