Oncology & Hematology Coding Alert

Question: Should I apply a modifier 25 onto an E/M visit code (992xx) when my oncologist performs a finger/heel/ear stick (36416) and orders labs (or at least 85025)?

Kentucky Subscriber

Answer: No. The visit code 992xx (Office or other outpatient visit …) does not require a modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) when 36416 is billed. A few reasons:

• For Medicare, 36416 is not payable service, but other payors may reimburse it, and no modifier is needed.
• If a venipuncture (36415, Collection of venous blood by venipuncture) is performed for the collection, it is paid under the clinical lab fee schedule, not the physician fee schedule.
• Claim edits do not require modifier 25 on the visit with 36415 or 36416, according the NCCI (National Correct Coding Initiative).

Lastly, the visit must be supported to report it. The documentation must support a significant, separately identifiable evaluation and management service. If the visit was simply a lab draw, only report the specimen collection (36415 or 36416) and the labs.

Heads up: CPT^® code 36415 is not designated in CPT^® as a “separate procedure.” Per NCCI, there is no bundling edit between an E/M service (such as, 99212-99215, 99201-99205) and a routine venipuncture or lab tests (such as, 36415). However, some commercial carriers may have their own policies regarding the application of modifier 25 on the E/M, on the same day as the blood specimen collection service.