Pediatric Coding Alert

Comfort: You're not alone in your  pulse oximetry denials
 
Correctly coded pulse ox claims don't necessarily ensure payment, but these tips may expose an overlooked reimbursement avenue.
 
The Office of Inspector General's increased scrutiny of modifier 25 and 59 claims has made many coders worry about their use of these tools on claims involving pulse oximetry. "I am very confused on how to use these modifiers correctly," says Cathy Mackie, a biller for Kids First Pediatrics in Highland Village, Texas.
 
When Mackie reports pulse oximetry with an office visit, a third-party payer bundles CPT 94760 (Noninvasive ear or pulse oximetry for oxygen saturation; single determination) into 9921x (Office or other outpatient visit for the evaluation and management of an established patient ...).   Should she use modifier 59 (Distinct procedural service) instead of modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) in these instances?
 
The bitter truth: Regardless of modifier, "almost none of the managed-care organizations (MCOs) pay for the pulse oxygen," says Richard Lander, MD, FAAP, pediatrician with Essex-Morris Pediatric Group in Livingston, N.J. To double-check if you're doing everything you can to avoid 94760 denials, take the following test. Take a Minute to Review Your Diagnoses Consider the following claim submitted to Pediatric Coding Alert by a fellow coder. After you review the services and procedures, try to code the claim yourself before you check out our expert advice below.
 
Decide whether you should use modifier 59 on 94640 for an encounter that involves:
 • 99215     Dx 493.00, 493.90
 • 94760
 • 94640
 • J7613
 • A7003
 • 94060 Hint: Each modifier indicates these encounter circumstances:

 • 25 -- identifies the E/M service as significant and separately identifiable from a same-day procedure or service performed by the same pediatrician
 • 59 -- indicates that the pediatrician rendered "either a procedure or a service that was different or independent from other things he did that day," Lander says. Step 1: Before you zoom in on the modifier as the potential key to unlocking payment for 94760, review your diagnoses. A fifth-digit subclassification of 2 -- 493.02 (Extrinsic asthma; with [acute] exacerbation) or 493.92 (Asthma, unspecified; with [acute] exacerbation) -- is probably more appropriate than the unspecified 0 digit, says Catherine A. Hudson, RMA, RPT, at Cumberland Pediatrics PC in Marietta, Ga. On claims involving this level of service (99215), "the child's condition is almost always exacerbated," she says.
 
In fact, you should use only the definitive diagnosis, such as 493.02, not the preliminary diagnosis (i.e., 493.92).
 
Step 2: Count your diagnoses. Case 1 contains only one diagnosis -- asthma. All the procedures including the pulse ox, inhalation treatment (94640, Pressurized or nonpressurized inhalation treatment for acute airway obstruction [...]