Question: An established type II diabetic patient comes in for a blood draw for glycohemoglobin. After the draw, the patient reports a sore left shoulder; she says it is a 4 on the 10 pain scale, with pain diminishing in the past few days. The nonphysician practitioner (NPP) takes a history related to shoulder pain, performs an examination of the shoulder, and diagnoses a mild coracohumeral sprain. The NPP recommends ibuprofen and rest for the shoulder, and sends the patient home. Should I roll the blood draw into the overall E/M level?
Answer: You should report separate codes for the NPP’s shoulder exam and blood draw, with corresponding diagnosis codes to separate the services. On the claim, report the following:
• 36415* (Collection of venous blood by venipuncture) for the draw
• 250.00 (Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled) appended to 36415 to represent the reason for the draw
• the appropriate E/M code (99211-99215) for the shoulder exam based on encounter notes
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to the E/M to show that the exam and the blood draw were separate services
• 840.2 (Sprains and strains of shoulder and upper arm; coracohumeral [ligament]) appended to the E/M to represent the patient’s shoulder injury.
Remember: The only reason you can report the appropriate E/M code here is that the reason for the patient’s shoulder symptoms, examination, and medical decision making were completely unrelated to the reason for the blood draw (diabetes). When the NPP performs only a blood draw, code 36415 represents the whole encounter.
Further, since the NPP addressed a new patient problem during the encounter, you cannot report this visit incident-to the physician. Report the entire claimunder the NPP’s national provider identifier (NPI).
* This code has a global surgical period of XXX. “Many of these ‘XXX’ procedures are performed by physicians and have inherent pre-procedure, intraprocedure, and post-procedure work usually performed each time the procedure is completed. This work should never be reported as a separate E/M code. However, appending modifier 25 to a significant, separately identifiable E&M service when performed on the same date of service as an ‘XXX’ procedure is correct coding,” states the Correct Coding Initiative (CCI), version 14.3.
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