Compliance Focus:
Pulse Oximetry
The local Medicare Intermediary recently published results of post payment review they conducted of various Massachusetts based providers of Pulse Oximetry services to determine if the services billed were medically necessary and that Medicare’s coverage requirements were met.
The CPT codes reviewed were: 94760 (Noninvasive ear or pulse oximetry for oxygen saturation; single determination) and 94761 (Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations). The denial rates of their review was 96 percent or greater.
The following were the reasons for their denials: documentation did not support medical necessity for the service billed; documentation did not support physician order(s); the number of services billed could not be validated.
To be covered, pulse oximetry services must be ordered by a physician and used in the active management of patient’s specific condition. Medical record documentation should be available, if requested, in supporting the medical necessity for each test billed. This includes, but not limited to, physician’s orders, treatment flow sheets, physician progress notes and nurses’ notes. While CMS does not require a specific format for information to be documented, service information contained in medical records should be clear, concise and structured in a way that clearly identifies and supports the services provided during a patient encounter. The medical record must also clearly identify who is rendering the service.
CPT codes 94760 and 94761 should be reported with only one unit of service per day, regardless of the number of determinations done on that day.
For more information, call or e-mail Neil Walsh at ext. 2-9377 or
CWALSH6@PARTNERS.ORG or Margo Clayman ext. 2-9384 in the Billing Compliance Department.