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 or for sputum induction for diagnostic purposes) and bronchodilation (94060, Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) pertain to the same diagnosis. Therefore, "there should be no need to use the 59," Lander says.

Consider 59 on Claims With Separate Diagnoses

When you perform a procedure with a distinct, separate diagnosis from another procedure, modifier 59 may come into play. Suppose little Suzy comes in with asthma and also has a paroncyhia incised and drained (I&D, 10060, Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single). In this scenario, Lander says, you could:
 
 • put 59 on the pulse ox code (94760-59)
 • list the E/M code for the asthma
 • use the I&D code with no modifier.

Alternative: You could instead indicate that the E/M service is significant and separate from the pulse ox, Lander says. Following this rationale, you would:

 • put 25 on the E/M service
 • list the two procedure codes using modifier 59 on the I&D.

Don't forget to link the ICD-9 code to the appropriate area, Lander says. The claim could contain:

 • 99215-25     Dx 493.02
 • 94760           493.02 
 • 10060-59      681.02 (Onychia and paroncyhia of finger).

In both instances, modifier 59 indicates that the procedure is separate and distinct from another procedure. Coding 94760-59 in the first 10060 coding example tells the payer that the pulse oximetry is a separate and distinct procedure from the I&D. Similarly, appending 59 on the I&D in the "alternative" coding example identifies 10060 as a separate, distinct procedural service from 94760.
 
Appending modifier 25 on 99215 to indicate that the E/M service is significant and separately identifiable from the procedures probably won't result in any pulse oximetry payment. Because Medicare considers 94760 included in a same-day E/M service, "most insurance companies will bundle the pulse ox with the main procedure code," Hudson says.
 
Ask yourself: In order to use modifier 59, do you need a different diagnosis? Absolutely not. A different diagnosis is something to consider, but you don't need one to use modifier 59.

Use 59 to Indicate Separate Site

You may have to use modifier 59 to identify a "separate procedure" code from another same-day procedure.

Consider which modifier(s) to use in this scenario:

 • 99213 Dx 493, 382.9, 380.4
 • 94760       493
 • 69210       380.4.

First, look at the ICD-9 codes listed. On the above claim, the coder links all three diagnoses to the E/M service -- a strategy you should avoid. If you give the office visit the same diagnoses as the procedures, you have no way of showing that the procedures are separate from the E/M service, Hudson says.
 
Astute readers will also notice that 493 is not coded at the highest level of specificity. It's missing a 4th and 5th digit, Hudson says. She's had success billing the encounter with these codes:

 • 99213-25       Dx 382.9 (Unspecified otitis media)
 • 94760            493.00
 • 69210-59       380.4 (Impacted cerumen)

Using modifier 59 on 69210 (Removal impacted cerumen [separate procedure], one or both ears) indicates that the cerumen removal is a separate and distinct procedure from the pulse oximetry. Because CPT designates 69210 as a separate procedure, insurers may bundle the code into other procedures. Modifier 59 alerts them to the fact that the removal occurs at a separate site from the other same-day procedure and thus should be paid separately.
 
In addition, modifier 25 tells the payer that 99213 is a significant and separately identifiable service from 94760 and 69210.