Advanced Search

Pulmonology Coding Alert

Reader Question:

Pulse Oximeter

Published on Sun Jul 01, 2001

Question: Many times the only way we can help a patient or qualify him or her for oxygen with Medicare is to do a pulse oximetry multi with exercise. However, we have been having trouble getting paid. Can we ask the patient to sign a waiver and pay for the pulse oximeter and attach modifier -GA to the procedure?

Oregon Subscriber
 
Answer: Payment for pulse oximetry (94760/94761) is bundled into the payment for any other service provided on the same day such as an office visit (99201-99215). Medicare will only pay for pulse oximetry if no other service payable under the physician's fee schedule is provided, and medical necessity for the procedure exists. When a procedure or service is deemed not medically necessary, reimbursement may be received if an advance beneficiary notice (ABN) exists. The ABN should be signed by the patient for that particular date of service and procedure, and the claim should be submitted to Medicare with the -GA modifier (waiver of liability statement on file) appended to the procedure. The ABN must be filled out prior to the procedure or service being performed so the beneficiary can decide whether or not he or she still wants the procedure or service.

When submitted to Medicare, the claim will be denied as "not reasonable or necessary." If there is no Medigap insurance to cover the cost, the beneficiary becomes liable for payment. ABNs are only necessary when a procedure or service is denied for "medical necessity." If a procedure or service is considered "non-covered," it will not be paid by Medicare. In this situation, an ABN is not required and the beneficiary is liable for the payment. The procedure/service should still be submitted to Medicare because the beneficiary may have secondary insurance that will cover it once the denial is received.

Other Articles in this issue of

Pulmonology Coding Alert

View All