CSHCN Services Program 2010 >30.2.34.3 Pediatric Pneumogram

A pneumogram is a 12- to 24-hour recording of breathing effort, heart rate, oxygen level, and airflow to the lungs during sleep. The study is useful in identifying abnormal breathing patterns, with or without bradycardia, especially in premature infants.

Procedure code 94772 is a benefit for CSHCN Services Program clients from birth through 12 months of age with one of the following diagnosis codes:


Diagnosis Code	Description
5300	Achalasia and cardiospasm
53010	Unspecified esophagitis
53011	Reflux esophagitis
53012	Acute esophagitis
53019	Other esophagitis
53081	Esophageal reflux
7685	Severe birth asphyxia
7686	Mild or moderate birth asphyxia
7689	Unspecified birth asphyxia in liveborn infant
769	Respiratory distress syndrome in newborn
7707	Chronic respiratory disease arising in the perinatal period
77081	Primary apnea of newborn
77082	Other apnea of newborn
77083	Cyanotic attacks of newborn
77084	Respiratory failure of newborn
77087	Respiratory arrest of newborn
77088	Hypoxemia of newborn
77089	Other respiratory problems of newborn after birth
78603	Apnea
78606	Tachypnea
78607	Wheezing
78609	Other dyspnea and respiratory abnormalities
79982	Apparent life threatening event in infant

Pediatric pneumograms are payable to physicians in office, inpatient hospital, outpatient hospital, and independent laboratory settings. A pediatric pneumogram is limited to two services without authorization based on the diagnoses listed above. Authorization is required for more than two pneumograms.

EMGs, polysomnography, EEGs, and ECGs are denied when billed on the same day as a pediatric pneumogram.

Pediatric pneumograms may be reimbursed on the same date of service as an apnea monitor (rented monthly) if documentation supports the medical necessity.

Pneumogram supplies are considered part of the technical component of the reimbursement and are denied if billed separately.