Wiki Billing therapeutic phlebotomy and E/M


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Pt is seen with hematochrosis, provider decides to perform a therapeutic phlebotomy -Code 99195 out of that new pt visit. How would you bill? I'm getting different answers...
Bill the E/M and the 99195, no mod needed?
Bill the 99195 only? Provider eats the E/M...
Bill the E/M and the 99195 with Mod-57?
If you go to the NCCI coding edits page ( and look up that code combination (99195 and 9920*), it tells you that a modifier is 'not applicable'. This means "This indicator means that an NCCI edit does not apply to this code pair. The edit for this code pair was deleted retroactively." according to the CMS manual for NCCI edits (

Based on my understanding on NCCI, I believe all of this means that both codes can be coded without modifiers. I do not bill for phlebotomy when I work so I might be wrong.
and because this is a new patient, the decision to perform the phlebotomy could not have been made prior to this visit (the phlebotomy was scheduled ahead of time), they should both be payable.
Any time the procedure is planned prior to the encounter, you do not bill an E&M. A therapeutic phlebotomy is most generally planned ahead.
Debra - Only asking about those new patients who are referred for the condition and not the actual phlebotomy.
Hope this helps

We sat down with a very reputable Medicare guru that shall remain nameless and gave several scenarios of what we do in the office and asked her how to bill them correctly.
Therapeutic phlebotomy was one of them. As long as the phlebotomy was not "planned" before the visit (seperately identifiable) we were told to bill it with a 25 modifier. If the phlebotomy was planned prior to the visit and nothing seperately identifiable was done you would eat the visit and only bill the phlebotomy. We have not had any issues with payment on any of these. Hope this helps.
I agree with skeeley in that a modifier 25 is necessary when an E&M is billed separately with a 99195. The 99195 has a global surgical indicator of XXX. Per the NCCI guidelines, the global rules do not apply to these codes. But they still require a modifier 25 on the E&M.

Source: NCCI Policy Manual, effective 1/1/2013; Chapt. 1, page I-18, I-19