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36.4.9.16 Pediatric Pneumogram
A pneumogram is a 12-hour 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.
Use procedure code 5/I/T-94772 when billing for the pediatric pneumogram.
The following diagnosis codes are payable for a pediatric pneumogram in infants up through 11 months of age:
EMGs, polysomnography, EEGs, and ECGs will be 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 will be denied if billed separately.
A pediatric pneumogram will be limited to two services without prior authorization based on the diagnosis codes listed in the previous table. Additional studies may be considered under THSteps-CCP with documentation of medical necessity, and will require prior authorization.
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