EM Coding Alert

Question: We are coding an office E/M code for a patient along with a single-reading pulse oximetry, and the payer is denying the service as bundled. I checked the Correct Coding Initiative (CCI), but could find no edits for office E/M codes and pulse oximetry code 94760. We have also submitted the claim with modifier 25 on the E/M and modifier 59 on 94760, with no success. How should I be coding this claim?

Washington Subscriber

Answer: If the physician performed the E/M and the oximetry on the same date of service, you won’t be able to unbundle the E/M code from 94760 (Noninvasive ear or pulse oximetry for oxygen saturation; single determination). On your claim, you should include the work the physician performed for the pulse oximetry when calculating the overall E/M level. Then, choose a code from the following sets, depending on patient status:

• 99201 (Office or other outpatient visitfor the evaluation and management of a new patient, which requires these 3 key components: a problem focused history; a problem focused examination; straight­forward medical decision making) through 99205 (… a comprehensive history; a comprehensive examination; medical decision making of high complexity) for new patients
• 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care profes­sional. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) through 99215 (Office or other outpatient visitfor the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity) for established patients.
• 99241 (Office consultation for a new or established patient, which requires all three key components; problem-focused history and examination with straightforward medical decision-making) through 99245 (Office consultation for a new or established patient, which requires all three key components of comprehensive history and examination with high medical decision-making).

Also: When pulse oximetry occurs on the same day as almost any E/M service, payers will consider it part of the E/M; for example, outpatient consultations (99241 to 99245) are also not separately payable.

Payers also include 94760 and 94761 (… multiple determinations [e.g., during exercise]) as elements of other reimbursed services such as a spirometry (94010), simple pulmonary stress test (94620), and respiratory therapy services (G0237, G0238, and G0239) if performed on the same day.

This is because Medicare assigns a “T” status for 94760 and 94761. That means payers always bundle reimbursement for these two pulse oximetry services and include it with the payment of any other service provided on the same day. So, you cannot get separate reimbursement for a pulse oximetry by trying to use a modifier with any of the codes.