Pulmonology Coding Alert

Despite Medicares recent decision to end separate pulse oximetry reimbursement, it is possible to get paid separately by using the correct ICD-9 codes and documenting in detail other services that may have been provided during the visit.

Background on Pulse Oximetry

Medicare and some private carriers had been bundling pulse oximetry (94760-94762) with evaluation and management services (99201-99215) in a confusing patchwork of reimbursement decisions that often left billers in the dark.

But Medicares recent decision to end pulse oximetry reimbursements Jan. 1, 2000, means commercial carriers will need to set their own courses of action. Under Medicares action, pulmonologists will no longer be able to bill separately for pulse oximetry using 94760 (noninvasive ear or pulse oximetry for oxygen saturation; single determination) or 94761 (multiple determinations, e.g., during exercise).

The codes were dismissed by the Health Care Financing Administration (HCFA), which last summer proposed rules declaring that along with taking a patients temperature and blood pressure, these pulse oximetry codes represented simple diagnostic procedures ... the technical work involved in these procedures is small, while the physician work involved in interpreting them is included in an evaluation and management service [visit] or a more complex procedure.

HCFA proposed giving the procedures the payment status B for payment always bundled into payment for other services. The proposal also bundled 94762 (pulse oximetry by continuous overnight monitoring).

Pulmonologists protested the proposed changes, prompting HCFA to make an adjustment in its plans. Pulse oximetry is not a routine diagnostic service like taking a patients blood pressure and family physicians or general practitioners commonly dont have the equipment in their offices, explains Sam Birnbaum, CMPE, executive director of Pulmonary Rehabilitation Associates of Youngstown, Ohio, and chair of the American College of Chest Physicians Practice Administration Section. These instruments are much more expensive to purchase and maintain than a thermometer or a sphygmometer. To suggest that the measurement of pulse oximetry is as routine and common as a blood pressure or a temperature is to suggest that all physicians should be required to include pulse oximetry for all patient visits.

In order for a COPD patient to qualify for supplemental home oxygen therapy, Medicare requires documentation of their oxygen saturation levels by either arterial blood gas studies or pulse oximetry, he says. Many times patients go home from the hospital with supplemental oxygen. We follow up with them in the office. If the pulse oximetry shows that theyve improved enough to discontinue the supplemental oxygen, weve saved Medicare a considerable amount of money.

HCFA agreed in its final rules, published in November, to let physicians continue to bill separately for the continuous overnight monitoring. The agency said that while the procedure usually occurred as a part of E/M services, we agree that the patients use of the oximeter [at home] is separate from the typical use of equipment during the E/M [visit] service.

However, HCFA refused to change its stance on the bundling status of codes 94760 and 94761, saying in its Final Medicare Fee Schedule that pulse oximetry was arguably less invasive than recording the patients temperature, another example of a diagnostic service for which we do not make separate payment. If interpretation of pulse oximetry or temperature data is complex, then that interpretation is clearly part of the medical decision making included in the E/M services.

Bundling in this case means that Medicare expects pulmonologists to continue performing pulse oximetry, says M. Ray Painter, MD, president of Physician Reimbursement Systems of Denver, Colo. They just wont pay for it.

Some Carriers Will Continue to Pay

But some carriers say theyll continue the reimburse
ments, just under their own terms. For example, Empire Blue Cross and Blue Shield, headquartered in New York, will continue to provide coverage for pulse oximetry in certain patient situations, according to the companys spokesperson, Mathew Slater. An independent licensee of the Blue Cross and Blue Shield Association and one of the associations largest plans, Empire serves 28 eastern and southeastern New York counties and multi-state employer groups. Empire also could set a precedent in the insurance business with its decision.

Coverage will be possible from Empire when:

The procedure is used as a diagnostic service, regardless of the patients age;

The equipment is rented for children up to 10 years of age who were born with hypoxia; and

The equipment is used for children up to 10 years who have developed hypoxia resulting from trauma or injury.

Empire Blue Cross and Blue Shield will not pay when a pulse oximetry is used as a monitoring device during surgeries, Slate relates.

Using ICD-9 Codes

Vicki Chapman, CPC, CCS-P, coding and compliance manager at West Texas Medical Associates in San Angelo, Texas, says other carriers still are bundling pulse oximetry E/M services because they consider routine oximetry to be incident to a physician's service. But Chapman says a separate payment for oximetry may be allowed by some carriers when accompanied by an appropriate ICD-9 code for a pulmonary disease(s) which is/are commonly associated with oxygen desaturation.

For carriers maintaining the status quo, medically necessary reasons for pulse oximetry include when the patient exhibits signs or symptoms of acute respiratory dysfunction (518.82) such as tachypnea (786.06), chronic dyspnea (491.20), cyanosis (782.5), respiratory distress (786.09), confusion (298.9) and hypoxia (799.0), says Chapman. She recommends that a corresponding diagnosis of symptoms be used to their highest level of specificity. A five-digit code provides more detail than a three- or-four-digit code. A three-digit code can be assigned, but only if there are no four-digit codes within that category.

Choose the code with the highest level of specificity, using signs and symptoms and diagnoses. For example, an ICD-9 code for acute bronchitis/bronchiolitis (466.0-466.1) would work with a CPT code for a pulse oximetry (94760, noninvasive ear or pulse oximetry for oxygen saturation; single determination).

Document In Detail

To improve your chances of having this procedure accepted for reimbursement, Chapman says you should make your first step to fully document the procedure in chart notes, including other services that may have been provided during the visit. Checklists or other efficiency tools are fine, she explains, but the history, physical, decision-making, and time must appear on the record to establish the level visit. For example, within each category or subcategory of E/M service, there are three to five levels of E/M services available for reporting purposes. The levels of E/M services encompass wide variations in skill, effort, time, responsibility and medical knowledge.

The certification of medical necessity should clearly document the reason for the testing, its frequency, and the results, Chapman stresses. Record the placement of the pulse oximetrywhether its on the finger or earand note the oxygen saturation levels, she says. Chart documentation shows the insurance carrier that youve performed separate servicesthat youve done a little extra work. Always record an appropriate history, physical exam and progress notes so all are available for review, she adds.

If the setting is a hospital, a nurse or auxiliary personnel employed by the physician can administer the oximetry. However, the physician must be present in the patients room for the duration of the procedure. The physician may supervise only one patient at a time during the procedure. The availability of the physician by telephone and the presence of the physician somewhere else in the setting does not constitute direct personnel supervision.

Tip: Note, however, that if the procedure occurs in a physicians office, the physician may supervise up to four patients at one time.

Modifier -25 Can Make a Difference

Lucy Brundage, president of Med/Surg Billing in Forest Park, Ill., and 16 years a medical coding consultant, says that for those private carriers who do pay on pulse oximetry, modifier -25 (significant, separately identifiable E/M service) must be attached to the 99213 code. As stated in the CPT manual, if you perform a separate evaluation and management [E/M] service on the same day as an operation or another service is provided, modifier -25 should be coded. Modifier -25 is intended to convey specific information regarding the procedure or service to which it is appended, she says.

Brundage cites the example of a patient who presents with shortness of breath that is later diagnosed as asthma (493.90, unspecified-without mention of status asthmaticus). Code the patient visit at level III (99213, 15 minutes)-because the physician will have to spend some time getting history and performing an exam, says Brundage.

Expect some carriers to still consider reimbursement for a pulse oximetry if it has a different diagnosis from the diagnosis for the level visit, she explains. It will pay for a certain level of diagnosis for oximetry. If a patient has asthma (493.90) and congestive heart failure (391.8), I would code the asthma for the level visit and congestive heart failure for the pulse oximetry. The idea is to use a different diagnosis, if you can.

Again, make sure to add -25 modifier to the office visit to indicate that the modifier should be paid separately. For the office or inpatient visit, the -25 modifier is attached to the end of the level visit to indicate that a service or procedure described in the code definition has been modified by some circumstance. This tells the carrier that were unbundling it from the E/M code and ICD-9 tells them why, explains Brundage.

Arterial Blood Gas

In the final Medicare rules, HCFA noted that physicians might discontinue pulse oximetry and instead refer patients for arterial blood gas determinations (82803analysis, and 36600arterial puncture).

Birnbaum says that arterial blood gas analysis may be used to make the initial determination that a patient requires supplemental oxygen. Often this test is performed on an inpatient basis when a patient has been admitted to manage respiratory distress and is included in the hospitals billing.

Charlie Strange, MD, FCCP, associate professor, Department of Pulmonary Medicine, Medical University of South Carolina, Charleston, S.C. and chair of the American College of Chest Physicians Section on Clinical Pulmonary Medicine, explains that pulse oximetry would be sufficient to determine if a patient needed to start on home oxygen. He adds that because of hospital admission restrictions, it is unlikely that a patient would be admitted only to determine the need for supplemental oxygen.

Coding Tip Summary

When appropriate use separate codes linking the E/M visit and ICD-9 codes, which will determine the CPT codes for pulse oximetry.

Although the physician is not required to administer
the oximetry, the physician must be present during the duration of the procedure.

Document where the pulse oximetry was performedfinger or earand the resulting oxygen levels.

Code the pulse oximetry procedure (94760, non-invasive ear or pulse oximetry for oxygen saturation; single determination).

Remember to attach modifier -25 onto the 99213-99215 E/M visit to ensure the carrier is aware that a separate procedure has been performed.