Pediatric Coding Alert

Question: If a patient comes in and has an E/M visit (99213), blood count (85024) and finger stick (36415), which procedure gets modifier -25?

Colorado Subscriber

Answer: You should always append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code, not the procedure. The modifier's definition describes a significant, separately identifiable E/M service. Therefore, you should append the modifier to that code.

Most carriers adopt Medicare's rules, which include an E/M with certain minor procedures, such as laceration repair (e.g., 12011* [Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less]) and cerumen removal (69210, Removal impacted cerumen [separate procedure]). In these situations, modifier -25 necessarily indicates that the E/M (e.g., 99211-99215, Established patient office visit) is separate from the procedure. The two additional codes that you indicate, however, do not include an E/M service.

The National Physician Relative Value Fee Schedule indicates whether a procedure contains preoperative and postoperative work. The file shows that 85024 (Blood count; hemogram and platelet count, automated, and automated partial differential WBC [CBC]) has XXX days for the global surgical period, meaning the code does not contain any E/M service. In fact, the lab code does not contain any work relative value units. The fee is for the test and does not include any physician work. Your office must have the appropriate Clinical Laboratory Improvement Act (CLIA) license to process this test in the office.

The routine venipuncture code is a starred procedure, which by definition includes the surgical procedure only. The fee schedule also designates 36415* (Routine venipuncture or finger/heel/ear stick for collection of specimen[s]) with XXX global days. The relative value units contain a fee for the finger stick only, and no physician or nurse work. Venipuncture code 36410* (Venipuncture, child over age 3 years or adult, necessi -tating physician's skill [separate procedure], for diagnostic or therapeutic purposes. Not to be used for routine venipuncture) also contains XXX global days.

The level-three office visit code (99213, Established patient office visit) is for the history, examination and medical decision-making that led to the decision to order the lab work. You should report the office visit, the blood count and the finger stick with no modifiers.