NCCI Version 20.1 Bundles Nurse Visit with Venipuncture
Learn to correctly unbundle codes for proper payment of these services.
By Erica T. Cousin, CPC, CPC-I
National Correct Coding Initiative (NCCI) version 20.1 includes code pair 36415 Collection of venous blood by venipuncture and 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services (a level 1 established patient evaluation and management (E/M), commonly called a “nurse visit”). The code pair includes modifier indicator 1 (see sidebar for description). What this means is that, when billing a nurse visit with venipuncture, you must ensure the provider documentation supports a medically necessary, significant E/M that was integral to the patient’s plan of care. You also must, when appropriate, append modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service to all nurse visits billed with venipuncture to receive reimbursement.
Follow Clinical Examples
- A patient presents for a prothrombin time/international normalized ratio (PT/ INR) lab test. The patient takes 5 mg of Coumadin® Monday – Friday, and 2.5 mg on Saturday and Sunday. The patient reports no change in medication or diet. A non-physician practitioner (NPP) performs a finger stick for the PT, and results are documented as 1.8. The patient is aware to continue this same Coumadin dosage and recheck PT in four weeks.
Proper coding is:
- 85610 Prothrombin time for the PT/INR
- 36416 Collection of capillary blood specimen (eg, finger, heel, ear stick) for the finger stick
- A patient presents for a PT/ INR lab test. He complains of frequent hunger, which has resulted in unwanted weight gain. The patient takes 5 mg of Coumadin on Tuesdays and 2.5 mg all other days. The patient reports changes in diet, but no changes in medication. An NPP performs a finger stick for the PT, and results are documented as 2.4. The NPP discusses the option of taking moderate walks for exercise and incorporating more fruits and vegetables into the patient’s diet. The patient’s vitals are taken and documented. The patient is aware to continue his same Coumadin dosage and to recheck his PT in four weeks.
Proper coding is:
- 85610 for the PT/ INR
- 36416 for the finger stick
- 99211-25 for the separately identifiable and significant nurse visit
As illustrated here, understanding when it is appropriate to use a modifier to override an NCCI code pair edit, and which modifier to use, is essential to appropriate reimbursement.
Deciphering Code Pairs
The Centers for Medicare & Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) code pair edits to define coding practices that result in inappropriate Medicare Part B payments. The agency regularly updates NCCI edits using various resources, including the American Medical Association, and national and local coverage determinations. CMS and other payers load the NCCI code pairs into their prepayment edits to prevent improper reimbursements.
You may interpret the NCCI code pair tables by comparing columns 1 and 2 to the modifier indicator column. Indicators 0, 1, and 9 specify whether you may append a modifier, when appropriate, to bypass NCCI edits, and thereby gain payment for the column 1/column 2 code pair:
0 – Columns 1 and 2 are mutually exclusive and cannot be reimbursed together.
1 – Columns 1 and 2 may be reimbursed with a modifier, when billed together.
9 – You may bill column 1 and column 2 codes together and receive reimbursement, without a modifier (The code pair edits were retroactively deleted.).
CMS published NCCI version 20.1 April 1, for implementation April 7. Version 20.1 contains more than 475 NCCI code pair additions for physician billing. You can download the updated NCCI code pair edits from the CMS website: www.cms.gov/apps/ama/license.asp?file=/NationalCorrectCodInitEd/downloads/MCR_NCCI_Changes.zip.
Erica T. Cousin, CPC, CPC-I, serves on the National Advisory Board for AAPC, Region 3. She manages the Central Charge Review department at Cornerstone Health Care in High Point, N.C. Cousin has worked in the healthcare industry for over 15 years in various capacities, including management, coding, accounts receivable follow up, and cash applications. She is a member of the Winston-Salem, N.C., local chapter.