ED Coding and Reimbursement Alert

Question: When billing 94760 we have always attached modifier -26 (professional component) because the physician is interpreting the reading, not performing the procedure. We recently received notification from one insurance company that attaching this modifier was incorrect. How do I code this correctly?
Indiana Subscriber

Answer: Routine billing for pulse oximetry on the professional side is not advisable, even with modifier -26 (professional component), because in many situations oximetry is a vital sign that nursing staff perform without an order. Its commonly incorporated with the level of service (99281-99285).

The only time you might use 94760 (noninvasive ear or pulse oximetry for oxygen saturation; single determination) is when it relates directly to the chief complaint. If, for example, the patient comes in with shortness of breath (786.05), the oximetry makes sense as an important part of the presenting problem. If the patient comes in with a sprained ankle (845.00), the oximetry is just a vital. Needless to say, if any of your payers indicate that they do not want the modifier, dont use it.

Note: Medicare will not reimburse a separately billed pulse oximetry.