Pulse Oximetry Interpretation FAQ

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FAQ 1: Can I bill Medicare for pulse ox interpretation in the ED (94760-94762)?

 

The simple answer is no.  And here is the reason (or reasons) why.

  • The CMS (Medicare) National Physician Fee Schedule Relative Value File does not assign any physician work for these codes.  This usually indicates codes that are unlikely to be billable by emergency providers.   
  • On the CMS fee schedule these codes are listed as Status A.  Which means these services are only paid if there are no other services payable under the physician fee schedule billed on the same date by the same provider for the same patient. If any other services payable under the physician fee schedule are billed on the same date by the same provider for the same patient, these Status A services are bundled into the physician services for which payment is made.    
  • The PC/TC indicator for these codes on the CMS fee schedule is 3.  This indicates Technical Component Only Codes.  These are codes that are covered only as diagnostic tests and therefore do not have a related professional code. Modifiers 26 and TC cannot be used with these codes.    

 

FAQ 2: Can I bill non-Medicare patients for pulse ox interpretation in the ED?

 

The answer is still no.  The above answers are all from CMS, which does only govern Medicare claims.  But CPT policy covers all claims utilizing CPT codes and nomenclature.  Per the CPT Information Services: “From a CPT Coding perspective, the purpose of codes 94760 and 94762 is to identify that the physician owns the equipment used for the oximetry and performed the interpretation of the results. Therefore, if the physician does not own the equipment used to perform the ear pulse oximetry, it would not be appropriate to report code 94760 or 94762 to identify his or her services. Interpretation of the ear or pulse oximetry results performed by the physician when the equipment is not owned by the physician (e.g. performed on hospital-owned equipment) is considered part of the medical decision making component of the evaluation and management (E/M) service codes".

 

FAQ 3  If the pulse ox interpretation is considered part of the E/M service can I count it additionally when determining the level of MDM (Medical Decision Making)?

 

The purpose of MDM is to represent the complexity of the physician‘s thought processes in evaluating and managing a given patient’s present, past, and potential medical problems.  In many emergency departments, oxygen saturation is documented as a part of the intake process for every patient.   The solitary act of recording the pulse ox reading by the nursing staff might not seem to communicate any added complexity of thought by the ED physician.  For example, if a patient with an isolated ankle sprain and no oxygen saturation coupled medical conditions has a pulse ox documented.

 

However, it may be reasonable to take pulse ox interpretation into account in cases where the patient’s medical condition(s) warrants the ED physician using the saturation reading as part of the diagnostic/management process: for shortness of breath,  chest pain,  history of respiratory ailments, child with bronchiolitis, etc.  In such cases, it would be prudent to document the relevance of pulse ox interpretation in the medical record.

 

 

Disclaimer

The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only.   The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date. The FAQs and Pearls are provided "as is" without warranty of any kind, either express or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Payment policies can vary from payer to payer. ACEP, its committee members, authors or editors assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of or relating to any use, non-use, interpretation of, or reliance on information contained or not contained in the FAQs and Pearls. In no event shall ACEP be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Specific coding or payment related issues should be directed to the payer. For information about this FAQ/ Pearl, or to provide feedback, please contact David A. McKenzie, CAE, Reimbursement Director, ACEP at (972) 550-0911, Ext. 3233 or dmckenzie@acep.org.

5-1-2017

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