Primary Care Coding Alert

Question: Is it possible to bill 99211 with 36415? If so, do I need to append modifier 25 to the 99211?

Texas Subscriber

Answer: Though a National Correct Coding Initiative (NCCI) edit prevents you from coding 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional…) with 36415 (Collection of venous blood by venipuncture), the edit allows use of a modifier to override it. Since 99211 is the column 2 code in the edit pair, you would need to append 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) to the E/M in that situation.

However, you must meet the requirements for billing the 99211. This means:

1. The patient must already be established with the physician.
2. The service must be face-to-face and not conducted via telephone or electronic media.
3. The documentation for the E/M service must establish there was a clinical need for it.

Additionally, as there are no key components (history, examination, or medical decision making) associated with 99211, the note must justify the clinical need for the encounter and that there was some evaluation and management of the patient. For this level of E/M, that could be something like following up on an already established plan of care by reviewing medications, checking blood pressure, and other such services that the physician had already ordered that are separate from 36415.

In other words, if the 36415 is a part of the patient’s ongoing plan of care and the encounter was simply for purposes of collecting the blood sample via venipuncture, you cannot bill for both services. But if the patient is there to receive treatment for an existing condition, and the E/M service is significant and separately identifiable from the venipuncture reported with 36415 (especially if the services are for unrelated purposes as demonstrated by the diagnosis codes), then the two services can be billed together with modifier 25 appended to 99211.

Example: A patient returns to have her dressings changed following minor surgery. At the same time, the patient tells the nurse changing the dressing that she has been feeling unusually fatigued. The nurse then performs a blood draw to see if the lab will shed some light on the patient’s tiredness. In this case, you should be able to bill 99211 for the dressing change and 36415 for the blood draw, attaching modifier 25 to the E/M service per payer preference.