Article on Ox Readings with an E&M charge
Found this article for you, hope it helps. Maybe you could get them to document at least the medical necessary reasons below that apply to that patient.
Oximetry Services CPT code 94760, 94761, 94762
Oximetry measures oxygen saturation using a non-invasive probe. This is done by measuring light absorption of oxygenated hemoglobin and total hemoglobin in arterial blood.
Medicare will allow payment for oximetry when accompanied by an appropriate ICD-9-CM code for a pulmonary disease(s) which is commonly associated with oxygen desaturation. Routine use of oximetry is non-covered.
Medically necessary reasons for pulse oximetry include:
1.) Patient exhibits signs or symptoms of acute respiratory dysfunction such as:
o Tachypnea.
o Dyspnea.
o Cyanosis.
o Respiratory distress.
o Confusion.
o Hypoxia.
2.) Patient has chronic lung disease, severe cardiopulmonary disease or neuromuscular disease involving the muscles of respiration, and oximetry is needed for at least one of the following reasons:
o Initial evaluation to determine the severity of respiratory impairment.
o Evaluation of an acute change in condition.
o Evaluation of exercise tolerance in a patient with respiratory disease.
o Evaluation to establish medical necessity of oxygen therapeutic regimen.
3.) Patient has sustained severe multiple trauma or complains of acute severe chest pain.
4.) Patient is under treatment with a medication with known pulmonary toxicity, and oximetry is medically necessary to monitor for potential adverse effects of therapy.
These services may be performed in the home or office by a provider or by an independent diagnostic testing facility.
The results of tests performed by a durable medical equipment supplier to qualify patients for home oxygen service are not covered.
Overnight Oximetry (94762) is considered medically necessary when performed for any of the following circumstances:
• The patient has a condition for which intermittent arterial blood gas sampling is likely to miss important variations.
• The patient has a condition resulting in hypoxemia and there is a need to assess supplemental oxygen requirements and/or a therapeutic regimen.
Compliance with the provisions in this LCD may be subject to monitoring by postpayment data analysis and subsequent medical review.
LCD Individual Consideration
Additional payment may be allowed for oximetric determinations exceeding the parameters described in the “Utilization Guidelines� section below on an “individual consideration� basis. The “LCD Individual Consideration� procedure is described in the related Article.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
• Safe and effective.
• Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
• Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
o Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member.
o Furnished in a setting appropriate to the patient's medical needs and condition.
o Ordered and furnished by qualified personnel.
o One that meets, but does not exceed, the patient's medical need.
o At least as beneficial as an existing and available medically appropriate alternative.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12X, 13X, 18X, 21X, 22X, 23X, 71X, 73X, 74X, 75X, 77X, 85X
Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X is effective for dates of service on or after April 1, 2010.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes.
Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance.
046X, 0410, 0412 and 0419
CPT/HCPCS Codes
Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
94760© Measure blood oxygen level
94761© Measure blood oxygen level
94762© Measure blood oxygen level
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis� editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
(Link:
http://www.medicarepaymentandreimbursement.com/2011/09/oximetry-services-cpt-code-94760-94761.html)
