tci E/M Coding Alert - 2020 Issue Q2

You Be the Coder: Modify Your Understanding of E/M-Venipuncture Encounters

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

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