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Overview: Medicare Reimbursement for Pulse Oximetry

Specific procedural requirements and rates for reimbursement can vary by geographical region, insurance company policies, and patient conditions. It is important that you contact your Medicare Contractor to verify reimbursement amounts and procedures for your region. For the most updated information on Medicare reimbursement for pulse oximetry and other procedures, please visit the Medicare Coverage Database.

Medicare will generally allow payment for pulse oximetry when accompanied by an appropriate ICD-9-CM code for a pulmonary disease(s) that is commonly associated with oxygen desaturation. Routine use of pulse oximetry is non-covered.

Medically necessary reasons for pulse oximetry include instances when patient exhibits signs or symptoms of acute respiratory dysfunction, such as:

  • Tachypnea
  • Dyspnea
  • Cyanosis
  • Respiratory Distress
  • Confusion
  • Hypoxia

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:

  • Initial evaluation to determine the severity of respiratory impairment
  • Evaluation of an acute change in condition
  • Evaluation of exercise tolerance in a patient with respiratory disease
  • Evaluation to establish medical necessity of oxygen therapeutic regimen
  • Patient has sustained severe multiple trauma or complains of acute severe chest pain
  • 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.

Chart of CPT Codes and ICD-9-CM Codes for Pulse Oximetry

Pulse Oximetry CPT codes and ICD-9 codes with clinical indications

CPT Codes

94760

Noninvasive ear or pulse oximetry for oxygen saturation; single determination

96761

Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations (eg, during exercise).

ICD-9 Codes

011.00-011.96

Tuberculosis of lung infiltrative confirmation unspecified – unspecified pulmonary tuberculosis tubercle bacilli not found by bacteriological histological examination but tuberculosis confirmed by other methods.

020.3-020.5

Primary pneumonic plague – pneumonic plague unspecified

021.2

Pulmonary tularemia

039.1

Pulmonary actinomycotic infection

052.1

Varicella (hemorrhagic pneumonitis)

073.0

Ornithosis with pneumonia

079.82

SARS-associated coronavirus infection

130.4

Pneumonitis due to toxoplasmosis

135

Sarcoidosis

136.3

Pneumocystosis

162.0-162.9

Malignant neoplasm of trachea – malignant neoplasm of bronchus and lung unspecified

163.0 – 163.9

Malignant neoplasm of pleura

197.0

Secondary malignant neoplasm of lung

277.00

Cystic fibrosis without meconium ileus

277.01

Cystic fibrosis with meconium ileus

277.02

Cystic fibrosis with pulmonary manifestations

277.03

Cystic fibrosis with gastrointestinal manifestations

277.09

Cystic fibrosis with other manifestations

289.0

Polycythemia secondary

293.0

Delirium due to conditions classified elsewhere

327.09

Other organic insomnia

327.21

Primary central sleep apnea

327.23

Obstructive sleep apnea (adult) (pediatric)

327.29

Other organic sleep apnea

335.20

Amyotrophic lateral sclerosis

357.0

Acute infective polyneuritis

358.00

Myasthenia gravis without (acute) exacerbation

358.01

Myasthenia gravis with (acute) exacerbation

391.8

Other acute pneumatic heart disease

392.0

Rheumatic chorea with heart involvement

398.91

Rheumatic heart failure (congestive)

402.01

Malignant hypertensive heart disease with heart failure

402.11

Benign hypertensive heart disease with heart failure

402.91

Unspecified hypertensive heart disease with heart failure

404.91

Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease Stage I through Stage IV, or unspecified

404.93

Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease Stage V or end stage renal disease

415.0

Acute cor pulmonale

415.11

Iatrogenic pulmonary embolism and infarction

415.12

Septic pulmonary embolism

416.0

Primary pulmonary hypertension

416.9

Chronic pulmonary heart disease unspecified

427.89

Other specified cardiac dysrhythmias

428.0

Congestive heart failure unspecified

428.1

Left heart failure

428.20-428.23

Unspecified systolic heart failure – acute on chronic systolic heart failure

428.30-428.33

Unspecified diastolic heart failure – acute on chronic diastolic heart failure

428.40-428.43

Unspecified combined systolic and diastolic heart failure – acute on chronic combined systolic and diastolic heart failure

428.9

Heart failure unspecified

464.51

Supraglottitis unspecified with obstruction

466.0-466.19

Acute bronchitis – acute bronciolitis due to other infectious organisms

478.30-478.34

Unspecified paralysis of vocal cords – complete bilateral paralysis of vocal cords

478.6

Edema of larynx

478.70

Unspecified disease of larynx

478.71

Cellulitis and perichondritis of larynx

478.74

Stenosis of larynx

478.75

Laryngeal spasm

478.79

Other diseases of larynx

478.8

Upper respiratory tract hypersensitivity reaction site unspecified

480.0

Pneumonia due to adenovirus

480.1

Pneumonia due to respiratory syncytial virus

480.2

Pneumonia due to parainfluenza virus

480.3

Pneumonia due SARS-associated coronavirus

480.8

Pneumonia due to other virus not elsewhere classified

480.9

Viral pneumonia unspecified

481

Pneumococcal pneumonia (streptococcus pneumoniae pneumonia)

482.1

Pneumonia due to pseudomonas

482.30-482.39

Pneumonia due to streptococcus unspecified – pneumonia due to other streptococcus

482.40

Pneumonia due to staphylococcus unspecified

482.41

Pneumonia due to staphylococcus aureus

482.49

Other staphylococcus pneumonia

482.81- 482.89

Pneumonia due to anaerobes – pneumonia due to other specified bacteria

483.0-483.8

Pneumonia due to mycoplasma pneumoniae – pneumonia due to other specified organism

484.1-484.8

Pneumonia in cytomegalic inclusion disease – pneumonia in other infectious diseases classified elsewhere.

485

Bronchopneumonia organism unspecified

486

Pneumonia organism unspecified

487.0

Influenza with pneumonia

487.1

Influenza with other respiratory manifestations

488

Influenza due to identified avian influenza virus

490

Bronchitis not specified as acute or chronic

491.1

Mucopurulent chronic bronchitis

491.20-491.21

Obstructive chronic bronchitis without exacerbation – obstructive chronic bronchitis with (acute) exacerbation

491.8

Other chronic bronchitis

491.9

Unspecified chronic bronchitis

492.0

Emphysematous bleb

492.8

Other emphysema

493.00-493.01

Extrinsic asthma unspecified – extrinsic asthma with status asthmaticus

493.10-493.11

Intrinsic asthma unspecified – intrinsic asthma with status asthmaticus

493.20-493.21

Chronic obstructive asthma unspecified – chronic obstructive asthma with status asthmaticus

493.81

Exercise-induced bronchospasm

493.82

Cough variant asthma

493.90-493.91

Asthma unspecified – asthma unspecified type with status asthmaticus

494.0-494.1

Bronchiectasis without acute exacerbation – bronchiectasis with acute exacerbation

495.0-495.9

Farmers’ lung – unspecified allergic alveolitis and pneumonitis

496

Chronic airway obstruction not elsewhere classified

500

Coal workers’ pneumoconiosis

501

Asbestosis

502

Pneumoconiosis due to other silica or silicates

503

Pneumoconiosis due to other inorganic dust

504

Pneumonopathy due to inhalation of other dust

505

Pneumoconiosis unspecified

506.0-506.9

Bronchitis and pneumonitis due to fumes and vapors – unspecified respiratory conditions due to fumes and vapors

507.0- 507.8

Pneumonitis due to inhalation of food or vomitus – pneumonitis due to other solids and liquids

508.0- 508.9

Acute pulmonary manifestations due to radiation – respiratory conditions due to unspecified external agent

510.0-510.9

Empyema with fistula – empyema without fistula

511.0-511.9

Pleurisy without effusion or current tuberculosis – unspecified pleural effusion

512.0-512.8

Spontaneous tension pneumothorax – other spontaneous pneumothorax

513.0-513.1

Abscess of lung – abscess of mediastinum

514

Pulmonary congestion and hypostasis

515

Postinflammatory pulmonary fibrosis

516.0-516.9

Pulmonary alveolar proteinosis – unspecified alveolar and parietoalveolar pneumonopathy

517.1

Rheumatic pneumonia

517.2

Lung involvement in systemic sclerosis

517.3

Acute chest syndrome

519.4

Disorders of diaphragm

710.1

Systemic sclerosis

714.81

Rheumatoid lung

748.61

Congenital bronchiectasis

780.01-780.09

Coma – alteration of consciousness other

780.39

Other convulsions

780.51

Insomnia with sleep apnea, unspecified

780.53

Hypersomnia with sleep apnea, unspecified

780.57

Unspecified sleep apnea

782.5

Cyanosis

785.0

Tachycardia unspecified

785.50

Shock unspecified

785.51

Cardiogenic shock

785.52

Septic shock

785.59

Other shock without trauma

786.00-786.09

Respiratory abnormality unspecified – respiratory abnormality other

786.3

Hemoptysis

786.50-786.59

Unspecified chest pain – other chest pain

786.6

Swelling mass or lump in chest

793.1

Nonspecific abnormal findings on radiological and other examination of lung field

799.01-799.1

Asphyxia - respiratory

807.4

Flail chest

958.7

Traumatic subcutaneous emphysema

987.9

Toxic effect of unspecified gas fume or vapor

997.3

Respiratory complications not elsewhere classified

998.81

Emphysema (subcutaneous) (surgical) resulting from procedure

V01.82

Exposure to SARS-associated coronavirus

V42.6

Lung replaced by transplant

V58.69

Long-term (current) use of other medications

V67.2

Follow-up examination following chemotherapy

The information provided herein is compiled from a variety of public resources and should be considered only as a general overview of the subject matter, not a definitive guide or instructions for obtaining Medicare reimbursement for medical services. Please consult with your Medicare Contractor to verify specific reimbursement procedures and amounts for your region.

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