cpt 36415 with office visit

The 36415 CPT code is a vital component of accurate billing and reimbursement for blood draw procedures in healthcare. It refers to the collection of venous blood by venipuncture, a procedure where a needle is inserted into a vein to collect a blood sample. Medical billers and coders must have a solid understanding of this code to ensure proper documentation and coding for billing purposes.

Key Takeaways:

The 36415 CPT code is used for reporting venipuncture procedures for blood collection.
It is particularly relevant for routine venipunctures that do not require physician skills.
Accurate documentation and coding are crucial for proper billing and reimbursement.
Modifiers can be used with the 36415 CPT code to provide additional information to payers.
Medicare has specific guidelines for using the 36415 CPT code.

What is the 36415 CPT code?

The 36415 CPT code is a vital component of medical billing for blood draw procedures. It specifically refers to the collection of venous blood through the process of venipuncture. Venipuncture involves inserting a needle into a superficial peripheral vein of the upper or lower extremities to extract a blood specimen.

This code is used for routine venipunctures that do not require the expertise of a physician. It plays a crucial role in accurately reporting and documenting the procedure, ensuring proper billing and reimbursement for healthcare providers.

Assigning the 36415 CPT code correctly is essential to avoid coding errors and maximize revenue for blood draw services. This code is used across various healthcare settings and is recognized by insurance payers, including Medicare and private insurance companies. By following the guidelines and ensuring accurate documentation, healthcare providers can optimize their billing processes and streamline reimbursement.

Uses of the 36415 CPT code

The 36415 CPT code is primarily used for blood draw procedures performed on superficial peripheral veins. Some common uses of this code include:

Routine blood tests
Monitoring medication levels
Diagnosing and managing various medical conditions

By accurately assigning the 36415 CPT code, healthcare providers can ensure transparent and consistent reporting of blood draw procedures.

Documentation requirements for the 36415 CPT code

Accurate documentation is essential when using the 36415 CPT code for blood draw procedures. The following information should be documented:

Date and time of the procedure
Location of the venipuncture
Type of specimen collected
Procedure description, including the number of attempts, if applicable
Patient’s identification information

Proper documentation provides a comprehensive record of the blood draw procedure, ensuring accurate coding and billing for reimbursement. It also helps in maintaining patient records and healthcare continuity.

Guidelines for using the 36415 CPT code

When using the 36415 CPT code for blood draw procedures, it is important to adhere to specific guidelines to ensure accurate billing and reimbursement. Here are some important points to keep in mind:

Use the 36415 CPT code only for routine venipuncture procedures that involve the collection of blood from superficial peripheral veins of the upper and lower extremities.
Verify that the blood draw procedure meets the criteria for using the 36415 code, which does not require the skill of a physician.
Ensure that the documentation accurately supports the use of the 36415 code, including the reason for the blood draw, the location of the venipuncture, and any relevant modifiers.
Follow any specific guidelines provided by Medicare or private insurance companies for using the 36415 code, such as frequency limitations or documentation requirements.
Keep updated with any changes or updates to the guidelines for using the 36415 code to avoid potential billing errors or claim denials.

Example of Guidelines for Using the 36415 CPT Code:

Reimbursement for the 36415 cpt code.

The reimbursement for the 36415 CPT code can vary depending on the specific policies of the payer, such as Medicare or private insurance companies. Understanding the reimbursement rules and guidelines is essential for accurate billing and maximizing reimbursement for blood draw services.

In order to ensure proper reimbursement, it is crucial to accurately document and code the procedures associated with the 36415 CPT code. This involves providing sufficient information about the blood draw services performed, including the date, location, and details of the procedure.

Medicare, as well as other payers, may have specific requirements and documentation guidelines that need to be followed. Familiarizing yourself with these guidelines can help minimize claim denials and ensure appropriate reimbursement.

Working with a professional medical billing service, like XYZ Medical Billing, can greatly assist in navigating the complexities of reimbursement for the 36415 CPT code. Their expertise in dealing with various payers and understanding the intricacies of medical coding and billing can help streamline the reimbursement process for blood draw procedures.

In summary, understanding the reimbursement rules and guidelines for the 36415 CPT code is crucial for accurate billing and maximizing reimbursement. By ensuring accurate documentation and coding, healthcare providers can minimize claim denials and optimize their revenue for blood draw services.

Common Misconceptions about the 36415 CPT Code

While the 36415 CPT code is widely used for blood draw procedures, there are common misconceptions that can lead to coding errors and reimbursement issues. It’s important to address these misconceptions to ensure accurate billing and maximize reimbursement.

Misconception 1: Billing for 36415 is not necessary

Some healthcare providers believe that they don’t need to bill for the 36415 CPT code because it is a routine procedure. However, accurately reporting this code is crucial for proper documentation and reimbursement.

Misconception 2: 36415 is the only code for blood draws

Another misconception is that the 36415 code is the only code used for blood draw procedures. While it is the most commonly used code, there are other codes that may be appropriate depending on the specific circumstances. It’s important to consult the CPT guidelines and use the most accurate code for each scenario.

Misconception 3: 36415 covers all types of blood draws

Some providers mistakenly assume that the 36415 code can be used for all types of blood draws, regardless of the location or complexity. However, this code specifically applies to routine venipunctures on superficial peripheral veins of the upper and lower extremities. For specialized or complex blood draws, other CPT codes may be more appropriate.

Misconception 4: 36415 is universally reimbursed

Though the 36415 code is commonly reimbursed, reimbursement policies can vary among different payers and insurance plans. It is crucial to understand the reimbursement rules set by Medicare, private insurance companies, and other payers to avoid claim denials and ensure accurate reimbursement.

By dispelling these misconceptions and understanding the correct usage of the 36415 CPT code, healthcare providers can improve their coding accuracy, avoid billing errors, and maximize their reimbursement for blood draw procedures.

Accurate documentation plays a crucial role in ensuring proper billing and reimbursement for blood draw procedures using the 36415 CPT code. Here are some important documentation requirements to keep in mind:

1. Patient Information

Include the patient’s full name, date of birth, and any relevant identification numbers.
Ensure that the patient’s information is complete and accurate to prevent any potential billing issues.

2. Procedure Details

Specify the date and time of the blood draw procedure.
Describe the purpose of the blood draw, such as diagnostic testing or monitoring.
Include any relevant findings or observations during the procedure.

3. Medical Necessity

Document the medical necessity of the blood draw procedure to support accurate billing.
Include the reason for the blood draw and any relevant medical conditions or symptoms.

4. Ordering Physician Information

Provide the full name and NPI (National Provider Identifier) of the ordering physician.
Include any necessary documentation to verify the physician’s authorization for the blood draw procedure.

5. Supporting Documentation

Attach any supporting documents, such as laboratory requisitions or test orders, to validate the medical necessity of the blood draw.
Include any additional documentation required by specific payers for reimbursement purposes.

By ensuring accurate and comprehensive documentation, healthcare providers can minimize billing errors and optimize reimbursement for the 36415 CPT code. Remember to maintain proper record-keeping practices and stay up-to-date with any changes in documentation requirements to avoid potential claim denials.

Using Modifiers with the 36415 CPT Code

Modifiers can enhance the information provided by the 36415 CPT code when billing for blood draw procedures. These modifiers offer additional details to the payer, ensuring accurate coding, and reducing the risk of claim denials. Here are some common modifiers that are frequently used in conjunction with the 36415 CPT code:

Modifier -25: This modifier indicates that a separate and distinct evaluation and management service was provided by the same physician or qualified healthcare professional on the same day as the blood draw procedure.
Modifier -59: This modifier is used to indicate that a procedure or service was distinct or independent from other services performed on the same day.
Modifier -91: When multiple laboratory procedures are performed on the same day, this modifier denotes repeat testing to ensure accuracy of results.
Modifier -QP: This modifier signifies that a patient has opted for the Low-Dose Flu Vaccine rather than the standard dose.

By appropriately utilizing these modifiers, healthcare providers can provide necessary information to payers, accurately reflect the complexity of services rendered, and ensure optimal reimbursement for blood draw procedures.

Medicare Guidelines for the 36415 CPT Code

When billing the 36415 CPT code to Medicare, it is important to adhere to specific guidelines. Medicare has established requirements for the use of this code to ensure accurate billing and reimbursement. Here are some key points to keep in mind:

Only report the 36415 CPT code for routine venipuncture procedures that do not involve the skill of a physician.
The 36415 CPT code is applicable to blood draw procedures performed on superficial peripheral veins of the upper and lower extremities.
Ensure the service is provided by a qualified healthcare professional or a qualified technician under the supervision of a physician.
Properly document the medical necessity and reason for the blood draw procedure in the patient’s medical record.
Use the appropriate modifiers if applicable to indicate special circumstances related to the procedure.
Follow Medicare’s coding and billing rules to avoid claim denials and maximize reimbursement.
Stay up-to-date with Medicare’s updates and guidelines regarding the use of the 36415 CPT code.

By following these Medicare guidelines, healthcare providers can ensure compliance with billing regulations and receive appropriate reimbursement for blood draw services.

The role of medical billing services for the 36415 CPT code

Medical billing services play a crucial role in ensuring accurate billing and reimbursement for the 36415 CPT code. At Medical Bill Gurus, we specialize in navigating the complexities of medical coding and billing, working with all insurance payers, including Medicare and private insurance companies.

With our expertise, healthcare providers can streamline their billing processes and maximize their revenue. We understand the importance of accurate and timely reimbursement, and our team is dedicated to ensuring that healthcare providers receive the payment they deserve.

By partnering with us, healthcare providers can focus on delivering quality patient care while leaving the complex and time-consuming task of medical billing to our experts. We are committed to helping healthcare providers optimize their revenue and navigate the ever-changing landscape of medical billing.

Importance of Accurate Medical Coding for the 36415 CPT Code

Accurate medical coding plays a vital role when using the 36415 CPT code for blood draw procedures. It ensures that healthcare providers receive appropriate reimbursement for their services and minimizes the risk of claim denials and audits. At Medical Bill Gurus, our team of professional medical coders recognizes the significance of accurate coding and billing practices. By entrusting your medical coding needs to us, you can be confident in the precision and integrity of your billing process.

The Role of Accurate Coding

Accurate coding is crucial for healthcare providers as it directly impacts their revenue cycle. Assigning the correct CPT code, such as the 36415 code for blood draw procedures, ensures that healthcare services are accurately documented and billed. An incorrect or inaccurate code can lead to under or overbilling, resulting in financial loss or potential legal implications.

Minimizing Claim Denials and Audits

By implementing accurate medical coding practices, healthcare providers can minimize the risk of claim denials and audits. Insurance companies and regulatory bodies closely scrutinize claims to ensure compliance with coding guidelines, documentation requirements, and billing regulations. Inaccurate coding increases the chances of claims being rejected or audited, leading to delays in reimbursement and potential financial penalties.

Optimizing Reimbursement

Accurate medical coding serves as the foundation for optimal reimbursement. By correctly coding services provided, healthcare providers can maximize their revenue potential. It ensures that reimbursement is aligned with the complexity and extent of the services rendered, helping healthcare organizations sustain financial viability and deliver quality patient care.

The Expertise of Medical Bill Gurus

At Medical Bill Gurus, our team of highly skilled medical coders are well-versed in the complexities of the healthcare industry. We stay up-to-date with the latest coding guidelines and requirements to ensure accurate coding and billing practices. By partnering with us, you can have peace of mind knowing that experienced professionals are handling your medical coding needs.

Accurate medical coding is the foundation of a successful revenue cycle. By leveraging the expertise of Medical Bill Gurus, healthcare providers can ensure their coding and billing practices meet the highest standards of accuracy and compliance. Contact us today to learn more about how our medical coding services can optimize your revenue and streamline your billing process.

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The 36415 CPT code is a crucial component of accurately billing and reimbursing blood draw procedures in the healthcare industry. It plays a vital role in ensuring proper documentation and coding for venipuncture, the procedure of collecting blood samples through the insertion of a needle into a vein. Understanding the guidelines and requirements for using this code is essential for medical billers and coders to ensure accurate and timely reimbursement.

By partnering with Medical Bill Gurus, healthcare providers can benefit from our expertise in medical billing services. Our team of professionals specializes in navigating the complex world of medical coding and billing, working with all insurance payers including Medicare. With our help, you can streamline your medical billing processes, minimize errors, and optimize your revenue.

If you’re looking to enhance your medical billing practices, don’t hesitate to contact Medical Bill Gurus today. Our dedicated team is ready to assist you in improving efficiency and accuracy in your medical billing procedures. Let us handle the complexities of medical coding and billing, while you focus on delivering quality patient care.

The 36415 CPT code refers to the collection of venous blood by venipuncture, a procedure where a needle is inserted into a vein to collect a blood sample. This code is specifically for routine venipunctures that do not require the skill of a physician and are performed on superficial peripheral veins of the upper and lower extremities.

What are the guidelines for using the 36415 CPT code?

When using the 36415 CPT code, it is important to accurately assign the code for proper billing and reimbursement. Some guidelines to follow include ensuring that the procedure is a routine venipuncture, performed on superficial peripheral veins, and does not require the skill of a physician.

How much reimbursement can I expect for the 36415 CPT code?

The reimbursement for the 36415 CPT code varies depending on the payer and specific billing policies. It is important to understand the reimbursement rules set by Medicare, private insurance companies, and other payers to maximize reimbursement for blood draw services.

What are some common misconceptions about the 36415 CPT code?

Some common misconceptions about the 36415 CPT code include confusion about the type of procedure it represents, the skill level required to perform the procedure, and the documentation requirements for accurate billing.

What are the documentation requirements for the 36415 CPT code?

Accurate documentation is essential when using the 36415 CPT code for blood draw procedures. Important documentation requirements include documenting the date and time of the procedure, the location of the blood draw, the patient’s name and identification, and any relevant findings or complications.

Can modifiers be used with the 36415 CPT code?

Yes, modifiers can be used with the 36415 CPT code to provide additional information to the payer. Some common modifiers that may be used with this code include modifier 59 (distinct procedural service) and modifier 91 (repeat clinical diagnostic laboratory test).

What are the Medicare guidelines for the 36415 CPT code?

Medicare has specific guidelines for the use of the 36415 CPT code. It is important to follow these guidelines when billing this code to Medicare to ensure compliance and timely reimbursement.

How can medical billing services help with the 36415 CPT code?

Medical billing services, such as those provided by Medical Bill Gurus, specialize in navigating the complex world of medical coding and billing. They can ensure accurate billing and reimbursement for the 36415 CPT code, working with all insurance payers to maximize revenue for healthcare providers.

Why is accurate medical coding important for the 36415 CPT code?

Accurate medical coding is essential when using the 36415 CPT code to ensure appropriate reimbursement for blood draw procedures. Proper coding avoids potential claim denials and audits, maximizing revenue for healthcare providers.

What are the benefits of outsourcing medical billing services to Medical Bill Gurus?

By outsourcing medical billing needs to Medical Bill Gurus, healthcare providers can focus on delivering quality patient care while leaving the complex and time-consuming task of medical billing to the experts. Medical Bill Gurus specialize in comprehensive medical billing services, ensuring accurate and timely reimbursement for healthcare providers.

How can I contact Medical Bill Gurus for medical billing services?

To learn more about the medical billing services provided by Medical Bill Gurus and how they can help streamline the billing process for healthcare providers, contact their team at 1-800-674-7836.

How can I stay informed with Medical Bill Gurus for healthcare billing updates?

Medical Bill Gurus is committed to keeping healthcare providers updated with the latest billing regulations and guidelines. Follow Medical Bill Gurus for regular updates and tips on medical billing practices to ensure compliance and maximize revenue potential.

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How To Use CPT Code 36415

CPT 36415 describes the procedure of collecting a venous blood sample by inserting a needle into a vein. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 36415?

CPT 36415 is used to describe the procedure of collecting a blood sample from a vein. It involves the insertion of a needle into a vein, usually on the upper arm or elbow, to obtain the sample for diagnostic testing or other purposes.

2. Official Description

The official description of CPT code 36415 is: ‘Collection of venous blood by venipuncture.’

3. Procedure

The healthcare provider cleanses the venipuncture site with an antiseptic, typically 70% alcohol, and allows it to dry.
An elastic band is wrapped tightly around the upper arm to make the vein more visible and accessible.
The provider inserts a needle slowly into the vein, being careful not to puncture the posterior wall of the vein.
Approximately 5 mL of blood is drawn into a collection tube.
The needle is removed, and direct pressure is applied to the puncture site to stop any bleeding.

4. Qualifying circumstances

CPT 36415 is performed when a healthcare provider needs to collect a venous blood sample for diagnostic testing or other purposes. It is typically used for routine venipuncture or finger/heel/ear stick procedures. Modifier 63 should not be reported in conjunction with CPT 36415.

5. When to use CPT code 36415

CPT code 36415 should be used when a healthcare provider performs a venipuncture to collect a blood sample from a vein. It is appropriate for routine venipuncture procedures and should not be used for arterial punctures or other types of blood collection methods.

6. Documentation requirements

To support a claim for CPT 36415, the healthcare provider must document the following information:

The reason for the venipuncture procedure
The specific site of the venipuncture
The date and time of the procedure
The amount of blood collected
Any complications or additional procedures performed
The provider’s signature

7. Billing guidelines

When billing for CPT 36415, ensure that the procedure involves the collection of venous blood by venipuncture. It should not be reported with modifier 63. Consider the range of venipuncture and transfusion procedures (36400-36460) when selecting the appropriate code for billing.

8. Historical information

CPT 36415 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

A phlebotomist collecting a blood sample from a patient’s vein for routine laboratory testing.
A nurse performing a venipuncture to obtain a blood sample for a patient’s annual physical examination.
A medical technologist collecting a blood sample from a patient for a specific diagnostic test.
A healthcare provider performing a venipuncture to obtain a blood sample for a research study.
A physician collecting a blood sample from a patient to monitor their medication levels.
A nurse practitioner performing a venipuncture to obtain a blood sample for a patient’s preoperative evaluation.
A laboratory technician collecting a blood sample from a patient for a blood transfusion.
A healthcare provider performing a venipuncture to obtain a blood sample for a patient’s genetic testing .
A phlebotomist collecting a blood sample from a patient’s vein for a drug screening.
A nurse performing a venipuncture to obtain a blood sample for a patient’s pregnancy test.

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How to properly document and bill for venipuncture

Keep these tips in mind when documenting and billing for venipuncture.

What is the correct way to code for venipuncture? Does the billing change if the procedure is performed by a medical assistant (MA) instead of a physician?

If your physician has seen the patient prior to the MA performing the venipuncture (on the same day or a previous date) and instructs the MA to perform the venipuncture, the billing is the same regardless of whether the physician or MA actually performs the service, based on incident-to guidelines. Just make sure that the physician’s order and the performance of the venipuncture are documented.

Here are some coding tips:

1. Select the right code. Venipuncture coding is described using CPT 36415 (collection of venous blood by venipuncture).

2. Don’t append modifier -63. Modifier -63 describes a procedure performed on an infant less than 4 kg. CPT instructs us that use of modifier -63 with 36415 is inappropriate.

3. Report a single unit of 36415, per episode of care, regardless of how many times venipuncture is performed. This instruction comes from the 2018 National Correct Coding Initiative (NCCI) Policy Manual, Chapter V: Respiratory, Cardiovascular, Hemic and Lymphatic Systems CPT Codes 30000-39999. The Policy Manual stipulates:

CPT code 36415 describes collection of venous blood by venipuncture. Each unit of service (UOS) of this code includes all collections of venous blood by venipuncture during a single episode of care regardless of the number of times venipuncture is performed to collect venous blood specimens. Two or more collections of venous blood by venipuncture during the same episode of care are not reportable as additional UOS [Units of Service].

Per the Policy Manual, “An episode of care begins when a patient arrives at a facility for treatment and terminates when the patient leaves the facility.”

Medicare will not reimburse for routine venipuncture, and neither will many private payers.

CPT includes codes to report venipuncture requiring a physician’s skill, which are chosen according to the patient’s age and, for those patients younger than 3 years old, by the vein accessed:

36400 Venipuncture, younger than age 3 years, necessitating physician skill, not to be used for routine venipuncture; femoral or jugular vein
36405 scalp vein
36406 other vein
36410 Venipuncture, age 3 years or older, necessitating physician skill (separate procedure), for diagnostic or therapeutic purposes (not to be used for routine venipuncture)

Medicare will separately reimburse for 36400-36410, but only if documentation supports medical necessity. Documentation should describe the circumstances requiring physician skill.

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CPT code venipuncture – 36415 and 36416 -Billing Tips – Not seperately paid

by Lori | 2 comments

Procedure Codes and Definitions

36415 Collection of venous blood by venipuncture – Fee schedule amount $3.10 – Private insurance pay upto $15

36416 Collection of capillary blood specimen (eg, finger, heel, ear stick) Fee schedule amount $3.1

P96l5 – Catheterization for collection of specimen(s)

General Definition

Venipuncture or phlebotomy is the puncture of a vein with a needle to withdraw blood. Venipuncture is the most common method used to obtain blood samples for blood or serum lab procedures, and is sometimes referred to as a “blood draw.”

Venipuncture is the process of withdrawing a sample of blood for the purpose of analysis or testing. There are several different methods for the collection of a blood sample. The most common method and site of venipuncture is the insertion of a needle into the cubital vein of the anterior forearm at the elbow fold

Collection of a capillary blood specimen (36416) or of venous blood from an existing access line or by venipuncture that does not require a physician’s skill or a cutdown is considered “routine venipuncture Venipuncture Venipuncture is the process of withdrawing a sample of blood for the purpose of analysis or testing. There are several different methods for the collection of a blood sample. The most common method and site of venipuncture is the insertion of a needle into the cubital vein of the anterior forearm at the elbow fold. Please refer to the coding section of this policy for the procedure code most applicable to the method of blood withdrawal.

This policy addresses the Health Plan’s reimbursement policies pertaining to clinical laboratory and related laboratory services (e.g., venipuncture and the handling and conveyance of the specimen to the laboratory) for professional provider claims submitted on a Form CMS-1500, whether performed in a provider’s office, a hospital laboratory, or an independent laboratory

When blood is drawn to be sent to a reference lab, use code 36415 for the venipuncture. HCPCS Code G0001 was deleted in 2005. The most appropriate current code for G0001 is 36415 and the current fee for this is $3.00.

• CPT 36415 will not be separately reimbursed when submitted with the following CPT codes:

80048 82247 82728 83655 84450 85651 80050 82306 82784 83891 84460 85652 80051 82310 82785 84132 84550 86003 80053 82378 82947 84144 84702 86038 80055 82465 82948 84146 84703 86304 80061 82533 82950 84153 85007 86308 80069 82550 82951 84402 85013 86592 80074 82565 82962 84403 85014 86677 80076 82575 83001 84432 85018 86703 82040 82607 83036 84436 85025 86706 82105 82627 83516 84439 85027 86787 82150 82670 83540 84443 85610

• CPT 36416 will not be separately reimbursed when submitted with the following CPT codes:

80061 82947 83036 85014 85027 82247 82948 83655 85018 85610 82465 82962 85013 85025

Routine Venipuncture and the Collection of Blood Specimen from BCBS

A. Routine Venipuncture/Capillary Blood Collection Routine venipuncture CPT codes 36415 and S9529 and capillary blood collection code 36416, are eligible for separate reimbursement when reported with an E/M and/or a laboratory service. Unless an additional routine venipuncture/capillary blood collection is clinically necessary, the frequency limit for any of these services is once per member, per provider, per date of service. The frequency limit will also apply to any combination of these codes reported on the same date of service for the same member by the same provider. (See also our Frequency Editing Reimbursement Policy.)

In addition, HCPCS code G0471 for the collection of venous blood by venipuncture or urine sample by catheterization from an individual in a skilled nursing facility (SNF) or by a laboratory on behalf of a home health agency (HHA) collected by a laboratory technician that is employed by the laboratory that is performing the test will be eligible for separate reimbursement when reported with a laboratory service.

Frequently asked Questions

when should venipuncture be avoided? When there is an obvious infection in the skin Scar is extensive when Hematoma was previously identified when there is an edema noticed in the extremity Avoid when there is a fistula or cannula already available in the arm

does Medicare pay 36415? Yes, Medicare pays approximately $3 per encounter

how often can you bill 36415 ? It can be billed only once per day

what does 36415 bundled with ? Venipuncture does not require a modifier to override the edits.

who can bill 36415 ? Physician or Other qualified healthcare professional who often provide this service when ordering a lab test

Medicaid Update for CPT 36415

A specimen collection fee is limited only to venipuncture specimens drawn under the supervision of a physician to be sent outside of the office for processing. Any blood test obtained by heel or finger stick will post a mutually exclusive edit with 36415 – venipuncture. The following codes have been added as mutually exclusive to 36415: 82948–blood glucose, reagent strip, 85013–spun hematocrit, 85014–hematocrit, 85610–Prothrombin time, 83036– glycated hemoglobin, and 86318 –immunoassay for infectious agent by reagent strip when submitted with the modifier QW.

Codes eligible for separate reimbursement when reported with a laboratory service: Code Description

36415 Collection of venous blood by venipuncture

36416 Collection of capillary blood specimen (e.g., finger, heel, ear stick)

G0471 Collection of venous blood by venipuncture or urine sample by catheterization from an individual in a SNF or by a laboratory on behalf of a HHA

S9529 Routine venipuncture for collection of specimen (s), single home bound, nursing home, or skilled nursing facility patient

36591 Collection of blood specimen from a completely implantable venous access device

36592 Collection of blood specimen using established central or peripheral venous catheter Billing and Coding Guidelines

A. Routine Venipuncture/Capillary Blood Collection

Routine venipuncture CPT codes 36415 and S9529 and capillary blood collection code 36416, are eligible for reimbursement when billed with an E/M and/or a laboratory service. Unless an additional routine venipuncture/capillary blood collection is clinically necessary, this service is only eligible for reimbursement once per member, per provider, per date of service.

CPT 36415 is only eligible to be billed once, even when multiple specimens are drawn or when multiple sites are accessed in order to obtain an adequate specimen size for the desired test(s). ODS does not allow separate reimbursement for CPT 36415 (venipuncture) when billed in conjunction with a blood or serum lab procedure performed on the same day and billed by the same provider (procedure codes in the 80048 – 89399 range). 36415 will be denied as a subset to the lab test procedure.

If some of the blood and/or serum lab procedures are performed by the provider and others are sent to an outside lab, CPT 36415 is not eligible for separate eimbursement.

Venipuncture is the most common method used to obtain blood samples for blood or serum lab procedures. The work of obtaining the specimen sample is an essential part of performing the test. Reimbursement for the venipuncture is included in the reimbursement for the lab test procedure code.

Venipuncture is only eligible to be billed once, even when multiple specimens are drawn or when multiple sites are accessed in order to obtain adequate specimen size for the desired test(s).

PacificSource does not allow separate reimbursement for venipuncture when billed in conjunction with the blood or serum lab procedure performed on the same day and billed by the same provider will be denied as a subset to the lab test procedure

Modifier 90 (reference laboratory) will not bypass the subset edit. The outside laboratory that is actually performing the test will need to bill ODS directly in order for 36415 to be separately reimbursable to the provider performing the venipuncture to obtain the specimen for the outside laboratory.

The use of modifier 59 with 36415 when blood/serum lab tests are also billed is not a valid use of the modifier. The venipuncture is not a separate procedure in this situation. ODS does allow separate reimbursement for CPT 36415 when the only other lab services billed for that date by that provider are for specimens not obtained by venipuncture (e.g. urinalysis)

UnitedHealthcare considers venipuncture code S9529 (Routine venipuncture for collection of Specimen(s), single homebound, nursing home, or skilled nursing facility patient) a nonreimbursable service. The description for S9529 focuses on place of service for a service that is more precisely represented by CPT code 36415 and reported with the appropriate CMS place of service code.

Codes 36415 and 36416 are only covered as Preventive when done for a preventive lab procedure that requires a blood draw.

FCHP will not reimburse separately for 36415 (collection of venous blood by venipuncture) and/or 36416 (collection of capillary blood specimen i.e., finger, heel, ear stick) when billed along with an E&M office visit (99201-05; 99211-15) or preventative medicine service (99381-87; 99391-97) or office-based lab CPT codes (i.e. CLIA waived tests).

• FCHP does reimburse 36415 when it is the sole service provided.

• FCHP does reimburse 36416 when it is the sole service provided.

The following procedures/services are included in reporting critical care when performed during the critical period and, therefore, should not be coded separately. Please see CPT for specific code definitions. 36000, 36410, 36415, 36540, 36600, 43752, 71010, 71015, 71020, 91105, 92953, 93561, 93562, 94002, 94003, 94004, 94660, 94662, 94760, 94761, 94762, 99090.

CPT code 36415 for Collection of venous blood by venipuncture is now payable by Medicare, but code 36416 Collection of capillary blood specimen (e.g., finger, heel, ear stick) remains as not payable by Medicare as a separate service.

From Anthem

Frequency/Maximum Occurrences per Code Group: Identifies when procedures within a code grouping are reported more than the once per date of service in any combination, our editing systems will allow one service within the grouping.

Example: Routine blood collection codes 36415, 36416, and S9529 are considered to be the same service; therefore, when all of these codes are reported on the same date of service by the same provider for the same patient, only one of the procedures will be allowed for that date of service.

Routine venipuncture CPT code 36415, and Healthcare Common Procedure Coding System (HCPCS Level II) S9529 and capillary blood collection code 36416, are eligible for separate reimbursement when reported with an E/M and/or a laboratory service. Unless an additional routine venipuncture/capillary blood collection is clinically necessary, the frequency limit for any of these services is once per member, per provider, per date of service. The frequency limit will also apply to any combination of these codes reported on the same date of service for the same member by the same provider.

Frequency Editing and Laboratory and Venipuncture

Limit blood collection to 1 per date of service for any code in group 36415 (Collection of venous blood by venipuncture), 36416 (Collection of capillary blood specimen (finger, heel, ear stick)), and S9529 (Routine venipuncture for collection of specimen(s), single homebound, nursing home, or skilled nursing facility patient).

CPT code 36416

CPT 36416 is designated as a status B code (bundled and never separately reimbursed) on the Physician Fee Schedule RBRVU file. ODS clinical edits will deny CPT code 36416 with explanation code WGO (Service/supply is considered incidental and no separate payment can be made. Payment is always bundled into a related service), whether 36416 is billed with another code or as the sole service for that date. This edit is not eligible for a modifier bypass.

Venous blood collection by venipuncture and capillary blood Specimen collection (CPT codes 36415 and 36416) will be reimbursed once per physician or other health care professional per patient per date of service. When CPT code 36416 is submitted with CPT code 36415, CPT code 36415 is the only venipuncture code considered eligible for reimbursement. No modifier overrides will exempt CPT code 36416 from bundling into CPT code 36415.

When bill with office visit CPT code use Modifier 25 with E & M CPT code like 99211.

Multiple Venipuncture on Same day would be reimbursed for one unit.

STEPS TO FOLLOW IN PERFORMING A VENIPUNCTURE

1. If blood does not flow immediately, several steps can be taken to obtain the specimen.

a. Change the position of the needle. The needle may have penetrated the vein too far. In that case, pull back gently. If the needle has not penetrated far enough, gently push it in. Use the free index finger to feel above the puncture to locate the vein. Do not probe through tissue. This is painful and damaging. It may be just necessary to change the needle angle slightly. The bevel of the needle may be up against the vein wall and may be obstructing the blood flow.

b. Sometimes the Vacutainer tubes will lose vacuum and will not fill. In this case, try another tube.

c. Sometimes the tourniquet is so tight that it is obstructing blood flow. Loosen the tourniquet to see if this helps.

2. If blood still does not flow trying another site may be necessary, preferably in the other arm. Never stick a patient more than twice. After two unsuccessful tries, call someone else more experienced. By this time, the phlebotomist and the patient have lost confidence.

NOTE: You should never attempt an arterial stick or a stick to a foot vein without an order from the physician. An arterial stick is very traumatic to the patient and can result in serious, permanent damage to the circulation in that limb and to the nerves in that area. (Refer to the arterial puncture procedure for more details concerning the risks involved in arterial punctures.) Sticking a foot vein also involves risk, especially to a diabetic patient or any patient with poor circulation, due to risk of infection. If you cannot obtain blood from the arm by way of venipuncture (maximum of two attempts), ask another phlebotomist to try. Only after we have exhausted all other means, should an arterial puncture or a foot-puncture be attempted, and then only with a physician’s order.

3. As soon as the blood starts to flow, loosen the tourniquet. Remember, if the tourniquet is left on too long, the blood in this area will have an increased concentration of cells (hemoconcentration) and test results may be affected. If the veins are very small, leave the tourniquet on until the collection is complete. Always remove the tourniquet before removing the needle. The patient may open his fist as soon as the blood flow starts.

4. Apply clean, dry gauze to the site and gently withdraw the needle. Immediately lock the safety shield in place over the needle.

5. Apply gentle pressure to the point of the puncture until the bleeding has stopped. The patient should keep arm straight and/or elevate it above the heart. After the bleeding stops, apply a pressure bandage to the site, unless the patient refuses. Instruct the patient to leave the bandage on for at least 15 minutes. (NOTE: The patient may apply pressure if able.)

6. Dispose of needle and needle holder by way of Bio-Hazard sharp container.

7. PROPERLY LABEL TUBES FROM THE ARMBAND. Computer labels may be used after comparing with the armband. All tubes must be labeled with the patient’s name, account number, date collected, time collected, and collector’s initials. Additionally, any tube collected for any Blood Bank test, must have the hospital number handwritten from the armband, unless the patient identification system label is used.

8. Clean the area. Never leave anything in a patient’s room unless isolation techniques are warranted. Remove gloves after each patient contact. Wash hands before leaving the patient’s room. Do not wear gloves while going from room to room.

PATIENTS WITH IVs

a. Blood may be drawn in an arm with an I.V. only if drawn below the I.V.

b. If the patient has an I.V., one alternative to an impossible venipuncture is to request the nurse in charge to disconnect the I.V., wait at least 2 minutes, and draw blood from the needle already in the vein. Just remember that at least 3 ml should be discarded before the samples are collected. This avoids dilution and contamination of the sample with the I.V. fluid. Alternately, venipuncture can be performed in this arm after the 2 minute wait.

c. Always have the nurse disconnect the I.V. Phlebotomists should never turn off or on the patient’s I.V.

d. Do not put a tourniquet on above an I.V. without checking with the nurse.

e. The phlebotomist should always check with the nurse or the lab supervisor/charge tech if there are any questions.

Note: Refer to the procedure, “Adverse Reactions to Phlebotomy” for additional information. If the patient develops a hematoma, excel bleeding, tingling in the arm, or any other adverse reaction, this should be reported to the patient’s nurse and documented. Inform your supervisor so that a Risk Management report may be initiated.

Reimbursement Guide for Routine Venipuncture and the Collection of Blood Specimen – BCBS A. Routine Venipuncture/Capillary Blood Collection

Routine venipuncture procedure codes 36415 and S9529 and capillary blood collection code 36416, are eligible for reimbursement when billed with an E/M and/or a laboratory service. Unless an additional routine venipuncture/capillary blood collection is clinically necessary, this service is only eligible for reimbursement once per member, per provider, per date of service. B. Collection of Blood Specimen

The Health Plan follows the 2013 procedure coding guidelines which state that procedure 36591-36592 should not be reported “…in conjunction with other services except a laboratory service.1 ” Therefore, these codes are only eligible for separate reimbursement when billed with a laboratory service.

IV. Handling, Conveyance of Specimen, and/or Travel Allowance

The Health Plan considers the handling, conveyance, and/or travel allowance for the pick up of a laboratory specimen, to be included in a provider’s management of a patient. Therefore codes 99000, 99001, P9603, and P9604 are not eligible for separate reimbursement. See also our Bundled Services and Supplies Reimbursement Policy.

Codes eligible for separate reimbursement when billed with a laboratory service:

36415: collection of venous blood by venipuncture

36416: collection of capillary blood specimen (e.g., finger, heel, ear stick)

S9529: routine venipuncture for collection of specimen (s), single home bound, nursing home, or skilled nursing facility patient

36591: collection of blood specimen from a completely implantable venous access device

36592: collection of blood specimen using established central or peripheral venous catheter

Codes not eligible for separate reimbursement:

99000: handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory

99001: handling and/or conveyance of specimen for transfer from the patient in other than a physician’s office to a laboratory

P9603: Travel allowance, one way in connection with medically necessary laboratory specimen collection drawn from homebound or nursing homebound patient; prorated miles actually travelled

P9604: Travel allowance, one way in connection with medically necessary laboratory specimen collection drawn from homebound or nursing homebound patient; prorated trip charge

Routine Venipuncture and/or Collection of Specimens

Venipuncture or phlebotomy is the puncture of a vein with a needle or an IV catheter to withdraw blood. Venipuncture is the most common method used to obtain blood samples for blood or serum lab procedures, and is sometimes referred to as a “blood draw.” The work of obtaining the specimen sample is an essential part of performing the test. Reimbursement for the venipuncture is included in the reimbursement for the lab test procedure code.

Collection of capillary blood specimen or a venous blood from an existing line or by venipuncture that does not require a physician’s skill or a cutdown is considered “routine venipuncture.” Professional and Clinical Laboratory Services: with E & M codes

Insurance does not allow separate reimbursement for venipuncture when billed in conjunction with the blood or serum lab procedure performed on the same day and billed by the same provider will be denied as a subset to the lab test procedure.

If some of the blood and/or serum lab procedures are performed by provider and others are sent to an outside lab, venipuncture is not eligible for separate reimbursement.

The use of modifier 59 with venipuncture when blood/serum lab tests are also billed is not a valid use of the modifier. The venipuncture is not a separate procedure in this situation.

Insurance does allow separate reimbursement for venipuncture when the only other lab services billed for that date by that provider are for specimens not obtained by venipuncture (e.g. urinalysis).

Collection of a capillary blood specimen is designated as a status B code (bundled and never separately reimbursed) on the Physician Fee Schedule RBRVU file. Insurance clinical edits will deny a collection of a capillary blood specimen whether it is billed with another code or as the sole service for that date. This edit is not eligible for a modifier bypass. For Inpatient Hospital Services:

A maximum of one collection fee (any procedure code) is allowed per specimen type (venous blood, arterial blood) per date of service, per CMS policy. Specimen collections out of an existing line (arterial line, CVP line, port, etc.) are not separately reimbursable. 11.13 Lab Handling Codes

The following procedure has been updated to follow Insurance claims editing software: Lab Handling Codes

• 36415—Collection of venous blood by venipuncture.

Our claims editing system may deny as unbundled when billed with any E&M, lab or other procedure codes.

• 36416—Collection of capillary blood specimen. Our claims editing system may deny as unbundled when billed with any E&M, lab or other procedure codes.

• 99000—Handling and/or conveyance of specimen for transfer from physician’s office to a lab.*

• 99001—Handling and/or conveyance of specimen for transfer from the patient in other than a physicians office to a laboratory.*

• 99002—Handling, conveyance, and/or any other service in connection with implementation of an order involving devices (e.g. designing, fitting, packaging, handling, delivering, or mailing) when devices such as orthotics, protectives, or prosthetics are fabricated by an outside laboratory or shop but which items have been designed, and are to be fitted and adjusted by the attending physician.*

*These codes (99000, 99001, and 99002) will deny as unbundled when billed with an E&M code.

CO-109: Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.

Codes: Multiple procedure codes, including CPT code 36415 Resolution/Resources

Payment for many services provided to beneficiaries that are in a skilled nursing facility (SNF) is made to the SNF and not to the individual provider. This payment methodology is known as SNF consolidated billing.

SNF consolidated billing applies to patients that are in a covered Part A stay

In order to submit claims correctly and prevent overpayments, it is imperative that you know if your patient is a SNF resident in a Part A covered stay prior to submitting the claim. The best way to verify a patient’s SNF status is to ask personnel at the SNF. The SNF will know if it is receiving payments from Medicare for that patient’s care.

In the Balanced Budget Act of 1997, Congress mandated that payment for the majority of services provided to beneficiaries in a Medicare covered SNF stay be included in a bundled prospective payment made through the fiscal intermediary/A/B MAC to the SNF. These bundled services had to be billed by the SNF to the FI/A/B MAC in a consolidated bill. No longer would entities that provided these services to beneficiaries in a SNF stay be able to bill separately for those services. Medicare beneficiaries can either be in a Part A covered SNF stay, which includes medical services as well as room and board, or they can be in a Part B non-covered SNF stay in which the Part A benefits are exhausted, but certain medical services are still covered though room and board is not.

There are exceptions to SNF consolidated billing. The best way to find out if your service is separately payable is to check the CMS SNF Consolidated Billing website external link . Go to the ‘Carrier File Explanation’ link to read the background information.

Go to the Contractor Update external link for the year in which your service was provided to download coding files If the service is an exception to SNF consolidated billing, it can be submitted to Palmetto GBA

If the service is not an exception to SNF consolidated billing, the Medicare payment for the service is included in the payment made to the SNF. Part B providers cannot be reimbursed separately for these services.

If you submit a claim to Palmetto GBA for a SNF resident and Palmetto GBA pays the claim, SNF consolidated billing may still apply. Claims may be paid in error when the Common Working File (CWF), which is a master eligibility file used by Medicare contractors, is not updated. One reason for delays in CWF updates is that SNFs may not file claims as quickly as Part B providers.

Venipuncture: Statutory Denials

Denial Reason, Reason/Remark Code(s)

PR-204: This service/equipment/drug is not covered under the patient’s current benefit plan

PR-49: These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam

CPT code: 36415

Resolution/Resources

Procedures that are submitted to Palmetto GBA, which would otherwise be considered ‘medically necessary’ and reimbursed accordingly, are denied as ‘non-covered routine services’ when submitted with certain diagnosis codes that indicate the services are performed in the absence of signs and symptoms.

The Centers for Medicare & Medicaid Services (CMS) does not require providers to submit claims for services that are excluded by statute under Section 1862(a) (1) of the Social Security Act. However, if the patient (or his/her representative) believes that a service may be covered and asks that a claim be submitted or desires a formal Medicare determination, you must file a claim for that service to effectuate the patient’s right to a determination

If you are submitting a non-covered service to Medicare for denial purposes, the service may be submitted with HCPCS modifier GY. This modifier lets us know that an item or service is statutorily excluded or does not meet the definition of any Medicare benefit.

Submitting Non-covered Services for Denial Purposes

CMS has developed new Advance Beneficiary Notice (ABN) forms. The new forms incorporate the ‘old’ Notice of Exclusion from Medicare Benefits (NEMB) language. You must use the revised CMS ABN if you are providing advance notice of non-coverage to a beneficiary. Use of the revised ABN is optional for services that are excluded from Medicare benefits. Access the revised ABN and other background information from the CMS website external link .

If you have obtained a valid ABN, submit claims for this service with HCPCS modifier GA. Refer to the Palmetto GBA Modifier Lookup tool (under Self Service Tools on home page) for information on HCPCS modifier GA.

BLOOD HANDLING – Medicaid Guidelines

The fee for blood handling is usually included in the reimbursement for the blood test. Situations in which the drawing, packaging, and mailing of a blood specimen are the only services provided are rare and include:

* A beneficiary that is referred to a laboratory for the sole purpose of drawing, packaging, and mailing a blood sample to MDHHS for blood lead analysis. The State provides lead-free vacutainers for the analysis. Requests for vacutainers and the samples for analysis should be sent to the MDHHS Bureau of Laboratories – Trace Metals Section. (Refer to the Directory Appendix for contact information.)

* A beneficiary occasionally requires blood tests that are not performed in conjunction with other reimbursable services. Whenever possible, the beneficiary should be sent to the laboratory that is to perform the test(s). If this is not practical (i.e., the laboratory is not a local facility) and the sole purpose of a visit is to draw, package, and mail the sample to a laboratory, the bloodhandling fee may be billed by the practitioner. The blood-handling fee is not a benefit when any other service is reimbursable on the same date of service.

* A beneficiary may be referred to a laboratory for the sole purpose of drawing, packaging, andmailing a blood sample to MDHHS for HIV-1 viral load analysis and/or CD4/CD8 enumeration. The State provides specimen containers and mailing kits for the analysis. Requests for supplies and samples for analysis should be sent to the MDHHS Bureau of Laboratories – Trace Metals Section. (Refer to the Directory Appendix for contact information.)

When billing Medicaid for services rendered, blood handling may be billed if the drawing, packaging, and mailing of a blood sample are the only services provided as described above. Procedure Code 36415 (routine venipuncture for collection of specimen[s]) and the U&C charge for the service must be used.

Lab payments for Specimen 36415

Blood-Specimen Collection, Processing, and Packaging Arrangements OIG has become aware of arrangements under which clinical laboratories are providing remuneration to physicians to collect, process, and package patients’ specimens. This Special Fraud Alert addresses arrangements under which laboratories pay physicians, either directly or indirectly (such as through an arrangement with a marketing or other agent) to collect, process,and package patients’ blood specimens (Specimen Processing Arrangements).5

Processing Arrangements typically involve payments from laboratories to physicians for certain specified duties, which may include collecting the blood specimens, centrifuging the specimens, maintaining the specimens at a particular temperature, and packaging the specimens so that they are not damaged in transport. Payments under Specimen Processing Arrangements typically are made on a per-specimen or per-patient-encounter basis and often are associated with expensive or specialized tests.

Medicare allows the person who collects a specimen to bill Medicare for a nominal specimen collection fee in certain circumstances, including times when the person draws a blood sample through venipuncture (i.e., inserting into a vein a needle with syringe or vacuum tube to draw the specimen).

Medicare allows such billing only when: (1) it is the accepted and prevailing practice among physicians in the locality to make separate charges for drawing or collecting a specimen and (2) it is the customary practice of the physician performing such services to bill separate charges for drawing or collecting the specimen.7

Only one collection fee is allowed for each type of specimen for each patient encounter, regardless of the number of specimens drawn.8

Physicians who satisfy the specimen collection fee criteria and choose to bill Medicare for the specimen collection must use Current Procedural Terminology (CPT) Code 36415, “Routine venipuncture – Collection of venous blood by venipuncture.

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what codes can I use to be reimburse the highest with code 36415?

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Medicare Guidelines visitors

Medicare payment basics

In the exam room, the distinction between one type of visit and another isn't always clear. It's important to know when — and how — you can bill for both .

BETSY NICOLETTI, MS, CPC, AND VINITA MAGOON, DO, JD, MBA, MPH, CMQ

Fam Pract Manag. 2022;29(1):15-20

Author disclosures: no relevant financial relationships.

In family medicine, it's common for a medical problem to crop up during a routine preventive visit, or for a preventive service to crop up during a problem-oriented visit. For example, let's say you're finishing up a Medicare annual wellness visit when the patient lifts his shirt and says, “Oh yeah, I'd also like you to look at this rash,” which results in a prescription. Or, at a follow-up visit for a patient's chronic condition, you notice he is overdue for a flu shot and colorectal screening, so you perform a preventive visit too.

From a coding perspective, there is a bright line between a preventive medicine visit and a problem-oriented visit. One is for promoting health and wellness, and the other is for addressing an acute or chronic medical problem. But in the exam room, the distinction isn't always clear. The question for family physicians is this: When does the work in the exam room warrant billing for two distinct services?

The answer lies in knowing the requirements for various preventive medicine and Medicare wellness visits, knowing when you've done enough beyond those requirements to also bill for a separate E/M service, and knowing how to document and code it all. The good news is the 2021 E/M coding changes made it easier than it used to be.

When physicians and other clinicians address a medical problem during a preventive or wellness visit, they can often bill for both services.

Knowing the core components of preventive or wellness visits can help physicians recognize when they have done enough work beyond those requirements to bill for a separate evaluation and management service.

Because preventive and wellness visits come with no cost sharing, it's best practice to explain to patients that a separate service performed during the same visit may result in a charge to them.

PREVENTIVE MEDICINE VISITS

Preventive medicine visits (CPT codes 99381-99397) are for patients covered by commercial insurance, Medicaid plans, and some Medicare Advantage plans. Patients value these visits because they are not subject to co-pays and deductibles. After age two, one preventive visit is covered annually.

According to CPT, preventive medicine visits are “comprehensive preventive medicine evaluation and management services of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures.”

Codes 99381-99387 are for new patients and 99391-99397 are for established patients. Both are further broken down by age group. The extent of the exam, the content of the counseling and anticipatory guidance, and the recommended screenings and immunizations vary depending on the patient's age and gender. “Comprehensive” in the CPT definition is not synonymous with the comprehensive exam required in other E/M services. This is a common misconception among physicians and patients alike.

CPT states that if a new or existing problem is assessed and managed at the time of the preventive visit, the physician should also bill a problem-oriented visit (an office visit) on the day of the preventive care. But insignificant problems that do not require extra work should not be billed as office visits. If a patient comes in for a preventive visit and the clinician also looks at a rash or notices the patient's blood pressure is elevated, these observations alone are not enough to bill a problem-oriented E/M visit. There must be some medical decision making (MDM) that occurs, such as prescribing a topical treatment for the rash or choosing not to prescribe a medication for the high blood pressure and instead suggesting the patient change his diet.

Once you've documented your MDM, you can bill an E/M visit using codes 99202-99215 with the preventive medicine visit code. Make sure to add modifier 25 to the E/M code to signal to the payer that two distinct visits were done on the same day.

For more details on when to bill both visits, how to level the E/M portion, and what to include in your documentation, see “ One visit or two? ”

ONE VISIT OR TWO?

Medicare wellness visits.

Original (traditional) Medicare does not cover CPT codes 99381-99397, because Medicare has its own wellness visits with their own “G” codes and requirements. As mentioned, some Medicare Advantage plans do cover the preventive medicine CPT codes in addition to Medicare wellness visits. However, a Medicare wellness visit and a preventive visit should not be billed on the same date of service. Medicare developed the Initial Preventive Physical Examination (IPPE, also known as the “Welcome to Medicare” visit) (G0402) and initial and subsequent annual wellness visits (G0438 and G0439) to encourage Medicare patients to receive screenings and preventive care, and to work with their physicians to develop a personalized prevention plan. 1 The requirements are slightly different for the three codes, but in general they require collecting or updating medical, family, and social history; screening for depression; evaluating the patient's ability to perform activities of daily living; assessing the patient's safety at home; recording vital signs; asking about opioid and substance use; and providing guidance about preventive services and a personalized prevention plan (for more details, see the table in “ Medicare 101: Navigating the Rules for Coverage and Benefits in Clinical Practice ”). Similar to CPT's preventive medicine visits, Medicare wellness visits do not require a full head-to-toe physical exam.

The assessment and management of acute or chronic problems are not components of the IPPE or annual wellness visits. When that service is medically necessary during a Medicare wellness visit, the physician can also bill for a problem-oriented E/M office visit on the same day, again using the appropriate CPT code (99202-99215) with modifier 25.

SELECTING THE LEVEL OF SERVICE FOR THE E/M CODE

Hopefully you're now familiar with the E/M coding rules that changed in 2021. 2 Performing a problem-oriented E/M service on the same date as a wellness visit adds a layer of complexity when it comes to choosing the level of service for the E/M code. But, as mentioned, the new rules actually make it easier than it was before.

When selecting a code (99202-99215) using the new E/M guidelines for office and outpatient services, physicians may use either total time on the date of the visit or MDM. History and exam are no longer necessary to select the level of service (though they should still be documented to provide the best care). This makes it easier to select a level of service for the problem-oriented visit when it's combined with a wellness or preventive visit because there are fewer overlapping components when coding based on MDM. The E/M service is your assessment and management of an acute or chronic condition, which is not required in either CPT preventive services or Medicare wellness visits.

It's trickier to code the E/M service based on time because you must make sure to only count the time spent managing the problems, not the time spent on the preventive or wellness service. The February 2021 CPT Assistant newsletter was particularly clear on this, stating “if time is used for selection of a level of the office/outpatient E/M code, the time spent on the preventive service cannot be counted toward the time of the work of the problem assessment because time spent performing a service cannot be counted twice. The code for the problem-assessment portion of the encounter will likely be selected based on MDM.” 3 It might make sense to consider MDM-based coding as the best practice when combining E/M visits with wellness visits.

A problem-oriented visit includes the history of the problem and any symptoms or complaints related to it. It may or may not include a physical exam or data review (e.g., notes reviewed, tests ordered, tests reviewed, or independent historian). It includes the evaluation and management of a problem or condition. When these components are documented in addition to the preventive visit, add a problem-oriented visit code. For more on which components are required for which visits, see “ How to credit combined visits .”

Let's look at some examples of when it would be appropriate to bill for a problem-oriented E/M code (CPT 99202-99215) along with a preventive or wellness visit.

Patient 1: A 70-year-old male, established patient with a history of diabetes and hyperlipidemia comes in for a Medicare annual wellness visit. All required components of the wellness visit are completed. The patient then asks for a refill of his diabetes medication. The physician asks the patient if he is taking his medication as prescribed and following the diet recommendations discussed during the last visit. The physician also performs a focused physical exam, discusses medication management for diabetes and hyperlipidemia, and orders maintenance labs. The physician documents her significant review of the patient's problems, bills for the annual wellness visit with code G0439, and adds a 99214 E/M code because she addressed two stable chronic illnesses and performed prescription drug management. She adds modifier 25 to the E/M code.

Patient 2: A 32-year-old female, new patient comes in for a preventive medicine visit required by her employer. The physician completes all requirements for the preventive visit. During the history portion, the patient tells the physician that she has been having some knee pain exacerbated by running. The physician obtains additional history about the pain, examines her knee, tells her to reduce her running until the pain subsides, and gives her a handout on knee exercises. He also recommends she try a knee brace and follow up if the pain does not lessen with rest. The physician documents the extra work done to address the knee issue, then bills code 99385 for an initial preventive medicine visit for a patient age 18–39, along with E/M code 99203 because he addressed one acute, uncomplicated injury. He adds modifier 25 to the E/M code.

Patient 3: A 49-year-old female, established patient comes in for her annual preventive visit. The physician completes all requirements for the preventive visit. The patient then mentions she has been excessively tired recently and has been having trouble sleeping. The physician obtains a detailed history of the problems, does a thorough physical exam, and orders some labs (complete blood count and thyroid-stimulating hormone). The physician documents the extra work, then bills code 99396 for a periodic preventive medicine visit for a patient age 40–64 and E/M code 99213 for addressing two acute illnesses (fatigue and insomnia) and ordering two labs. The physician adds modifier 25 to the E/M code.

WORKFLOW TIPS

It's hard to plan for surprise problems that come up during a preventive or wellness visit. But your staff can help by asking patients up front if they have any other issues that need to be addressed. This step should occur when staff are scheduling or confirming patient visits, allowing you to block off more time if necessary.

Scheduling staff should also be aware that Medicare wellness visits have strict rules about how often they can be billed. They must be separated by at least 12 months from the previous wellness visit. Having staff check eligibility for Medicare wellness visits using the HIPAA Eligibility Transaction System can help you avoid denials. 4 The timeframes for CPT preventive visits are more forgiving; they can be performed once every plan year (usually a calendar year, but some plans vary).

Patients who know their preventive/wellness visit will be covered with no deductible or co-pay may mistakenly assume all services provided during that visit, including E/M, will be no cost to them. It is best to educate patients on the costs associated with a problem-oriented office visit and let them know that performing one with a preventive or wellness visit will result in the same co-pay they would incur if the problem-oriented visit was on a different day. Most patients will accept this, because getting both visits in the same trip is more convenient for them. Posting flyers in the exam rooms or waiting room about the difference between preventive/wellness visits and problem-oriented visits, and the costs associated with each, can also prevent patient dissatisfaction.

Physicians could ask these patients to return for the problem-oriented visit on another day, but if time allows for providing both services at the current visit, it is only fair and reasonable to do so. Knowing the rules for combined visits, and the convenience they offer patients, should give physicians the confidence to bill fully for their services.

The ABCs of the Initial Preventive Physical Examination. Medicare Learning Network. Accessed Nov. 15, 2021. https://www.mvphealthcare.com/wp-content/uploads/download-manager-files/CMS-ABC-Initial-Preventive-Physical-Examination-ICN006904-01-2015.pdf

Millette KW. Countdown to the E/M coding changes. Fam Pract Manag . 2020;27(5):29-36.

Evaluation and management (E/M) 2021; AMA CPT Assistant . 2021;2:7-8.

HIPAA Eligibility Transaction System (HETS). Centers for Medicare & Medicaid Services. Updated Oct. 25, 2021. Accessed Nov. 15, 2021. https://www.cms.gov/research-statistics-data-and-systems/cms-information-technology/hetshelp

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