Internal Medicine Coding Alert

Question: I have tried several times to bill for O2 saturation (94760 or 94761) along with E/M service 99212-99214. Insurers always deny the O2 sat, saying it is included in the visit. The visit consists of the internist seeing the patient, taking BP etc., then if the patient is short of breath (SOB) we do the 02 sat. Do we need modifier 25 on the E/M visit for this to be paid?


California Subscriber


Answer: Most insurers bundle 94760 (Noninvasive ear or pulse oximetry for oxygen saturation; single determination) and 94761 (... multiple determinations) into 99212-99214 (Office or other outpatient visit for the evaluation and management of an established patient ...), regardless of modifier. These payment policies follow the National Correct Coding Initiative edits that include pulse oximetry in same-day E/M services (99201-99215).

The edits have modifier indicator 0, meaning you can never override the bundle. In other words, 94760-94761 are not separately reportable with 99201-99215.

Exception: Medicare pays 94760 only if the physician bills no other services on the same date that are payable under the physician fee schedule. If the provider bills any other services that are payable under the physician fee schedule on the same date, Medicare bundles the oxygen saturation services into the physician services for which payment is made.