Pulmonology Coding Alert

Question: We are billing an evaluation and management (E/M) code 99212 along with a pulse oximetry and these codes are being refused as bundled. There is no CCI edit for these codes. We provided the services in the office. We have tried to put a modifier 25 on the E/M and a modifier 59 on the 94760 but no success. How do I solve this problem?

Wisconsin Subscriber

Answer: According to your information, you’re trying to report codes 94760-94761 (Noninvasive ear or pulse oximetry…) along with office E/M code 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components:…). You should use the CPT® code 94760 for a single reading, while you’ll report 94761 for two or more readings. You can report the oximetry codes for reimbursement only when the pulmonologist’s staff measures either 94760 or 94761 in the office setting, and the patient receives no other service on that day.

Most of the payers consider the pulse oximetry codes 94760 and 94761 to be included in all E/M services, for example, outpatient office visits (99201 to 99215) or outpatient consultations (99241 to 99245) and therefore not separately payable. Payers also include 94760 and 94761 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. If you report a pulse oximetry separately, you will not receive any additional payments for this service in addition to the other procedures or the E/M service performed.

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.

Tip: Although 94760 and 94761 are inclusive in E/M services, overnight oximetry 94762 (Noninvasive ear or pulse oximetry for oxygen saturation; by continuous overnight monitoring [separate procedure]) is payable, it is not assigned a “t” status, and would not be reported on the same day as the E/M.