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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.26 Diagnostic Tests : Pediatric Pneumogram
A pediatric pneumogram (procedure code 94772) 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.
The following diagnosis codes may be reimbursed for a pediatric pneumogram in infants from birth through 11 months of age:
A pediatric pneumogram is limited to two services without prior authorization when submitted with one of the diagnosis codes listed above. Additional studies may be considered under CCP with documentation of medical necessity, and will require prior authorization.
Refer to:
Section 2: "Medicaid Children’s Services Comprehensive Care Program (CCP)" in the Children’s Services Handbook (Vol. 2, Provider Handbooks).
EMGs, polysomnography, EEGs, and ECGs are denied when billed on the same day as a pediatric pneumogram.
Pediatric pneumograms are reimbursed on the same day as an apnea monitor (rented monthly) if documentation supports the medical necessity.
Pneumogram supplies are considered part of the technical component and are denied if billed separately.

Texas Medicaid & Healthcare Partnership
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