Pediatric Coding Alert

Question: A child presents with fever, congestion and headache. The pediatrician takes a history, performs an evaluation and provides medical decision-making, during which she orders a fingerstick to collect a blood specimen to test the child's hemoglobin level. Should I report both the E/M service and the procedure?

Massachusetts Subscriber

Answer: Yes, you should report at least two codes for the encounter. Submit the appropriate-level E/M service, such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) or CPT 99214 . You should report the fingerstick with 36416 (Collection of capillary blood specimen [e.g., finger, heel, ear stick]). If you perform the test in your office, you should also assign 85018 (Blood count; hemoglobin [Hgb]) for the hemoglobin test.

Although 99213-99214, 36416 and possibly 85018 represent proper coding for your claim, insurers may not pay for the fingerstick. Medicare doesn't assign any relative value units to 36416 and doesn't separately reimburse the procedure.

Some insurers may have adopted Medicare's policy. For instance, Harvard Pilgrim HealthCare of New England won't reimburse 36416 when you bill the procedure in addition to an office visit or laboratory test. And Blue Cross Blue Shield of North Carolina considers 36416 incidental to E/M and surgical and laboratory services and won't separately reimburse the fingerstick in addition to any of these services. In these cases, you should write off the fingerstick charge.

If an insurer doesn't have a 36416 inclusion policy, make sure to appeal any denials. Code 36416 requires a significant amount of nurse work that warrants separate billing from the E/M service.