Question E/M and blood draw/injection same day

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Ok... this is probably a dumb question but it's stressing me out. The clinic I work for bills their E/M's on one claim and sends their 36415/96372 on a separate claim. It's mainly because their physician sees them first on one encounter and when the nurse comes in to do her part, she just bills her part out as soon as she's done on a separate encounter. Is this considered unbundling and possible fraud?
 

vanessamoldovan

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Ok... this is probably a dumb question but it's stressing me out. The clinic I work for bills their E/M's on one claim and sends their 36415/96372 on a separate claim. It's mainly because their physician sees them first on one encounter and when the nurse comes in to do her part, she just bills her part out as soon as she's done on a separate encounter. Is this considered unbundling and possible fraud?
This is not fraudulent because the reason for the process is for operational efficiency, not to try to get additional reimbursement. Per NCCI guidelines, 36415 is bundled into the office visit. Modifier 25 can be appended if the documentation supports it. If the documentation doesn't support it, then the 36415 should not be billed separately. If no modifier is appended, the payer will deny the unbundled service, regardless if the services are billed on the same or different claim. I hope this makes sense and eases your discomfort. :)
 
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This is not fraudulent because the reason for the process is for operational efficiency, not to try to get additional reimbursement. Per NCCI guidelines, 36415 is bundled into the office visit. Modifier 25 can be appended if the documentation supports it. If the documentation doesn't support it, then the 36415 should not be billed separately. If no modifier is appended, the payer will deny the unbundled service, regardless if the services are billed on the same or different claim. I hope this makes sense and eases your discomfort. :)
This makes total sense. Thank you!! :)
 
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