Ray Posted Fri 03rd of February, 2012 22:45:17 PM
we billed an office visit of 99213 along with a peak flow 94760 and nebulizer treatment of 94640. our office visit was denied payment because it was bundled with the 94640. the peak flow (94760) was billed with a modifier 25 but we were told that the office visit should have also been billed with a modifier. we have never billed a modifier for the office visit when billed with the 94760 or the 94640 but should we be billing with one? and if so is it the modifier 25?
SuperCoder Answered Sun 05th of February, 2012 04:59:58 AM
You may give a try using 25 modifier with 99213, but no guarantee of reimbursement.
But the Guidelines are as follows:
Medicare and many commercial carriers won't pay for the pulse oximetry codes 94760 (noninvasive ear or pulse oximetry for oxygen saturation; single determination) or 94761 (multiple determinations [for example, during exercise]) when billed in conjunction with evaluation/management (E/M) or other services.
Although the CPT guidelines allow separate coding of diagnostic tests ordered/interpreted during a patient E/M encounter (subsection "Levels of E/M Services" in the E/M Services Guidelines), Medicare ruled in 1999 that pulse oximetry is no more difficult than taking a patient's temperature and should be reflected as such. As a result, it is included in any E/M code submitted.
Medicare gives codes 94760–94761 a payment status of "T," which means they're bundled into any procedure or visit performed on the same day. This fact means that you cannot bill the pulse oximetry codes when any other code is billed for that date of service.
When no other service is provided on that day, you can bill pulse oximetry alone, but you'll still need to make sure your documentation supports medical necessity. Medicare will allow payment for oximetry when accompanied by an appropriate ICD-9-CM code for a pulmonary disease, which is commonly associated with oxygen desaturation.
Medically necessary reasons for pulse oximetry:
1. A patient exhibits signs or symptoms of acute respiratory dysfunction.
2. A patient has chronic lung disease, severe cardiopulmonary disease, or neuromuscular disease involving the muscles of respiration, and oximetry is needed for at least one of the following reasons:
-Initial evaluation to determine the severity of respiratory impairment.
-Evaluation of an acute change in condition.
-Evaluation of exercise tolerance in a patient with respiratory disease.
-Evaluation to establish medical necessity of oxygen therapeutic regimen.
3. A patient has sustained severe multiple trauma or complains of acute severe chest pain.
4. A patient is under treatment with a medication with known pulmonary toxicity, and oximetry is medically necessary to monitor for potential adverse effects.