Getting Paid for Pulse Ox

Question: I perform pulse oximetry in my office and noticed that I almost never get paid for this. Same with venipuncture codes. What am I missing here? I’m performing the services; the codes are in the book. Why no payment?

Answer: It’s called bundling. What the payers are telling you is that the payment for one code is essentially included in the payment of the other. Some people don’t even notice that it is happening. There are two kinds of bundling: those codes that are an integral part of another service and included in the CCI or Correct Coding Initiative edits, and the kind you are talking about - much stealthier!

You give a great example of this: pulse oximetry, code 94760. This is one of the first services I recall going the “incidental” route.

Back in the early 90s Medicare determined that the pulse oximetry service would not be “separately payable” along with an E&M code. The logic was, and is, that if one service has a significantly lower RVU value than another, then perhaps the two shouldn’t each have a separate payment when performed and billed together, but that only the higher one should be paid.

In today’s RVUs, a 99213 has a total nonfacility (office) RVU of 1.34 (not adjusted for location). A pulse ox (94760) has a total RVU of .07. This is 20 times less than that of the 99213. So, when performed together, the pulse ox is incidental to the 99213 because of the disparity in the weight or value of the two services - and the higher one is paid.

That doesn’t mean that a pulse ox can’t be paid. It has a fee schedule amount, it has an RVU, but it has such a small value when compared with almost any other code that it just doesn’t get paid along with much of anything else.

Of course if you bill it by itself, just a pulse ox, it is payable (at somewhere between $2 and $3)!

And this logic is being applied to more and more codes, or rather their RVUs. Venipuncture is also not often paid along with a visit code. This is payer-specific of course - and you need to find out how each payer does it, or where the RVU threshold is that determines what the difference in values needs to be for it to be deemed incidental.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or physicianspractice@cmpmedica.com.

This question originally appeared in the May 2010 issue of Physicians Practice.