use of 59 modifier on pulmonary procedures

[butterflysmile]

We have a situation in our Pedicatric doctors office verses our billing office. we bill a 94760 oxygen sat single with an E/M-25 only. our billing office have the system set up to edit the pulse oximetry to add the 59 modifier. i don't think i should be adding the 59 modifier on the first procedure line and it's the only procedure. our billing office says it's per the insurance guidelines, policies and from the appeals of denied claims to justify adding the 59 modifier. Should I be concern about this? Will this put our Pediactric office in jeopardy of an audit?

[ARCPC9491]

We have a situation in our Pedicatric doctors office verses our billing office. we bill a 94760 oxygen sat single with an E/M-25 only. our billing office have the system set up to edit the pulse oximetry to add the 59 modifier. i don't think i should be adding the 59 modifier on the first procedure line and it's the only procedure. our billing office says it's per the insurance guidelines, policies and from the appeals of denied claims to justify adding the 59 modifier. Should I be concern about this? Will this put our Pediactric office in jeopardy of an audit?

you are saying ......

992XX - 25
94760

the software says .......

992XX
94760 - 59?

survey says .......

Personally, I wouldn't code what the software says ... from the coding world, as long as documentation is supported, I would go with what you are saying. BUT you said that's how the insurance wants it to be coded? If so, I would go by what the insurance says. Every insurance is different and sometimes (most of the time ) it just doesn't make sense. chances are, in your instance, the insurances claim edit software probably doesn't recognize the first line item as an E/M. and sees it more as "two procedures". Just a guess. If that's what the insurance wanted, I don't see how you would be at risk for an audit. Make sure you get that in writing from them incase it ever were to happen.

-OR- you could code it as you originally said, wait for the denial and appeal it explaining the CPT coding guidelines.... and how they are wrong?

Just my 2 cents!