Primary Care Coding Alert

Question: Our payers deny a significant number of pulse oximetry codes because they state the test is part of that day's E/M charge. Our physician wonders if the denials are because we aren't appending modifier 25 to the E/M code. What's your advice?

Connecticut Subscriber

Answer: The problem probably lies in reporting an E/M code with the pulse oximetry, not just the fact that you might need to include modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

CMS stance: Medicare assigns a "T" status for codes 94760 (Noninvasive ear or pulse oximetry for oxygen saturation; single determination) and 94761 (Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations [e.g., during exercise]). That means the carrier always bundles payment for the pulse oximetry services into payment for any other service provided on the same day (including an E/M service). Do not  report 94760 or 94761 to CMS when the physician performs an office visit as the primary service on the same day.

CPT® guidelines: You have different directions, however, if your payer strictly follows CPT® guidelines. Coding notes instruct you to report the appropriate E/M code if the physician provides a separately identifiable E/M service during the same encounter. In that case, you should append modifier 25 to the E/M code.