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Pediatric Coding Alert

Reader Questions:

Modifier May Unlock 94760 Payment

Question: Is there any secret to getting payment for pulse oximetry test code 94760? Our insurance carriers are not paying this code.

North Carolina Subscriber Answer: Nonpayment stems from Medicare's fee schedule, which assigns T (Injections) status to 94760 (Noninvasive ear or pulse oximetry for oxygen saturation; single determination), meaning the code is only payable when no other service is payable that day. "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," according to Attachment A of the 2007 Medicare National Physician Fee Schedule Relative Value File.
Example: North Carolina Medicaid includes noninvasive pulse oximetry reimbursement (94760 and 94761) in the payment of other payable services provided on the same date of service. The NC Medicaid program allows separate reimbursement for noninvasive pulse oximetry only when you meet the following conditions:

 • the noninvasive pulse oximetry determination is the only service your practice provided.

 • you don't bill 94760 and 94761 with any other covered Medicaid service. Impact: Private payers may adopt Medicare's policy and include 94760-94761 in any other payable service that you bill on the same day. When you bill the code alone, expect national payment of about $2.65. The National Physician Fee Schedule assigns 0.07 transitional non-facility total relative value units to 94760 (0.07 RVUs x 37.8975 conversion factor).  
Tactics: Although CPT does not require modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) with 94760, try using the modifier on the E/M service code when appropriate.
For instance: To indicate that a level-four office visit for broncholitis is significant and separately identifiable from multiple pulse ox determinations (94761, ... multiple determinations [e.g., during exercise]), you could append modifier 25 to 99214 (Office or other outpatient visit for the evaluation and management of an established patient ...).
Consider trying to negotiate for pulse oximetry payment at contract renewal time. Check with your local chapter of the American Academy of Pediatrics for help in this area.