Wiki Adding Modifier 25 to E/M code when billing it with a 36415

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daphne34

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Hello,

I'm seeing lots of conflicting information in regards to coding an E/M with modifier 25 and coding a 36415 (Venipuncture). I would like some clarification/advice on this, is this the proper way to bill/code for this type of visit.

Thanks,
Daphne
 
Per the CCI edits an E&M code and 36415 are not bundled together; so technically a modifier 25 is not required. With that said many carriers will not pay on the 36415 as they consider it "bundled". So this is one of those grey areas. If the blood collection was truly separate from the E&M or reason for the visit then you would bill for the 36415.

The choice of the modifier 25 would be dependent on the carrier processing the claim. Some will pay them separately since there is no CCI edit, but if they have an internal bundling edit then a modifier 25 would be appropriate. Keep in mind that the modifier 25 is one of the coding issues closely monitored by the OIG. Just ensure that the medical records clearly support the billing of both codes.
 
Chelle-Lynn said:
Per the CCI edits an E&M code and 36415 are not bundled together; so technically a modifier 25 is not required. With that said many carriers will not pay on the 36415 as they consider it "bundled". So this is one of those grey areas. If the blood collection was truly separate from the E&M or reason for the visit then you would bill for the 36415.

The choice of the modifier 25 would be dependent on the carrier processing the claim. Some will pay them separately since there is no CCI edit, but if they have an internal bundling edit then a modifier 25 would be appropriate. Keep in mind that the modifier 25 is one of the coding issues closely monitored by the OIG. Just ensure that the medical records clearly support the billing of both codes.
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Thank you for this great information :)
 
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