How To Use CPT Code 94781

CPT 94781 describes the procedure for car seat/bed testing for airway integrity in infants up to 12 months of age. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 94781?

CPT 94781 can be used to describe the procedure for car seat/bed testing for airway integrity in infants up to 12 months of age. This code is used when a clinical staff person continually observes and evaluates an infant in a car seat or bed for airway integrity, while recording pulse oximetry, heart rate, and respiratory rate for an additional full 30 minutes after the first hour of observation. The service includes interpretation of the results and a report.

2. Official Description

The official description of CPT code 94781 is: ‘Car seat/bed testing for airway integrity, for infants through 12 months of age, with continual clinical staff observation and continuous recording of pulse oximetry, heart rate and respiratory rate, with interpretation and report; each additional full 30 minutes (List separately in addition to code for primary procedure)’

3. Procedure

  1. A clinical staff person continually observes and evaluates an infant in a car seat or bed for airway integrity.
  2. Pulse oximetry, heart rate, and respiratory rate are recorded continuously for an additional full 30 minutes after the first hour of observation.
  3. The provider interprets the results and prepares a report.

4. Qualifying circumstances

CPT 94781 is typically used for premature neonates or at-risk infants with conditions such as heart disease or congenital malformations before discharge home from the neonatal intensive care unit (NICU) or hospital. The procedure involves the continual observation of the baby in a car seat or bed while recording pulse oximetry, heart rate, and respiratory rate for an additional 30 minutes after the first hour of observation and recording.

5. When to use CPT code 94781

CPT code 94781 should be used when car seat/bed testing for airway integrity is performed on infants up to 12 months of age. It is important to note that this code should be used in conjunction with CPT code 94780, which covers the initial hour of observation and recording. CPT code 94781 is used for each additional full 30 minutes of observation and recording.

6. Documentation requirements

To support a claim for CPT code 94781, the provider must document the following information:

  • Infant’s age and any relevant medical conditions
  • Date and duration of the observation and recording period
  • Pulse oximetry, heart rate, and respiratory rate measurements
  • Interpretation of the results
  • Preparation of a report

7. Billing guidelines

When billing for CPT code 94781, ensure that the procedure is performed on infants up to 12 months of age and that the clinical staff person continually observes and evaluates the infant in a car seat or bed. This code should be listed separately in addition to the primary procedure code. It is important to note that CPT code 94781 should not be reported with other codes such as CPT codes 94766 to 94768, which cover telephone assessment and management services.

8. Historical information

CPT code 94781 was added to the Current Procedural Terminology system on January 1, 2012. There was a code change on January 1, 2019, which updated the description to specify neonates and nursing observation.

9. Examples

  1. An at-risk infant with congenital heart disease undergoing car seat testing for airway integrity. The clinical staff person continually observes and evaluates the infant in a car seat while recording pulse oximetry, heart rate, and respiratory rate for an additional 30 minutes after the initial hour of observation.
  2. A premature neonate being monitored for airway integrity in a bed. The provider records pulse oximetry, heart rate, and respiratory rate continuously for an additional full 30 minutes after the first hour of observation and recording.
  3. An infant with a congenital malformation undergoing car seat testing for airway integrity before discharge from the NICU. The provider interprets the results and prepares a report based on the continuous recording of pulse oximetry, heart rate, and respiratory rate for an additional 30 minutes after the initial hour of observation.
  4. A clinical staff person continually observes and evaluates an at-risk infant in a car seat for airway integrity. Pulse oximetry, heart rate, and respiratory rate are recorded continuously for an additional full 30 minutes after the first hour of observation.
  5. An infant with a heart condition undergoing car seat testing for airway integrity. The provider interprets the results and prepares a report based on the continuous recording of pulse oximetry, heart rate, and respiratory rate for an additional 30 minutes after the initial hour of observation and recording.

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