Pulmonology Coding Alert

Question:We are billing an evaluation and management (E/M) code 99212 along with a pulse oximetry and these codes are being refused as bundled. There is no CCI edit for these codes. We provided the services in the office. We have tried to put a modifier 25 on the E/M and a modifier 59 on the 94760 but no success. How do I solve this problem?

Wisconsin Subscriber

Answer:According to your information, you’re trying to report codes 94760 (Noninvasive ear or pulse oximetry…) along with office E/M code 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components:…). You should use the CPT® code 94760 for a single reading, while you’ll report 94761 for two or more readings. You can report the oximetry codes for reimbursement only when the pulmonologist’s staff measures either 94760 or 94761 in the office setting, and the patient receives no other service on that day.

Medicare assigns 94760 and 94761 with a “T’ status which means, “There are RVUs and payment amounts for these services, but they are only paid if there are no other services payable under the physician fee schedule billed on the samedate by the same provider. If any other services payable under the physician fee schedule are billed on the same date by the same provider, these services are bundled into the physician services for which payment is made.” Most otherpayers also consider pulse oximetry codes 94760 and 94761included in all E/M services, for example, outpatient office visits (99201 to 99215) or outpatient consultations (99241 to 99245) and therefore not separately payable. If you report a pulse oximetry separately, you will likely notreceive any additional payments for this service in addition  to the other procedures or the E/M service performed.