Pain Management Coding Alert

Question: Should I apply modifier 25 onto an evaluation and management (E/M) visit code (in this case, 99213) when my provider performs a finger/heel/ear stick (36416)?

Alabama Subscriber

Answer: No. The visit code 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components:

An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity …) does not require 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 you report 36416 (Collection of capillary blood specimen (eg, finger, heel, ear stick)) during the same patient encounter.

There are a few reasons for that:

• For Medicare, 36416 is not payable service, but other payers 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 to the National Correct Coding Initiative (NCCI).

Lastly, the visit must be supported to report it. The documentation must support a significant, separately identifiable E/M 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.