Q: Next question: “I am working on an A/R project and I’ve noticed that Blue Cross Blue Shield (BCBS) is denying CPT code 36415 as inclusive with 85025. Not sure if I’m supposed to submit an appeal or adjusting it off as inclusive. Please explain when you would use 36400, 36415, and 36416.”
A: I did a little of screen grabs of SuperCoder and I love SuperCoder for doing this. I just type in all the codes that I want to see stacked on top of each other and separate them by commas, and then I expand out the little check box so that I can see it all. So, here, we can get a quick overview because I know some people were saying on the last poll question like, “I don’t have my books,” but I try and give you what you would have found in your books in this little screen capture.
Medical Codes 36415 85025 – Video
OK. We’ve got that venipuncture for 36400 younger than age 3, that’s your 36400. And 415, is just a collection of venous blood by venipuncture. And 416, by finger, heel or ear sick. And then down in the lab section, 85025, is blood count complete. So, my first thing of that is like “No, those, it shouldn’t be bundled.” So I went in to SuperCoder and pop in the codes and I did not see any CCI edits. In my opinion, that should be paid, it should not be bundling your 36415 into your lab code. OK? So, I would appeal it.
Just as an aside, if you also billed an E/M code, the pair might be bundling it there. I’m not sure, you didn’t put that in your question, so I’m going to assume no, but I decided to throw that in there. I have read that there are some pairs that do bundle these two, so maybe Blue Cross Blue Shield is one of them. So, what I would recommend is doing a search of that payer’s website and see what their guidelines are regarding that particular code. So, I did do a search and I found this from Empire BlueCross BlueShield and here’s a link. If you’re in the Replay Club, you’ll get this in the answer sheet, and you can go to it.
In this III.A Routine Venipuncture/Capillary Blood Collection, it says: Routine venipuncture CPT code 36415 and this S code (S9529)… and 36416 are eligible for reimbursement when billed with an E/M with and/or a lab service.
So, if this is your particular BlueCross/BlueShield carrier, you could use this in an appeal letter. But it does go and to say: Using an additional routine venipuncture/capillary blood collection is clinically necessary; this service is only eligible for reimbursement once per member, per provider, per date of service.
So, that could be something that you might want to check. If it’s the second time you tried to code a 36415 on the same date of service that could be why they are not paying it. Anyway, look at your particular payer’s policy, see that helps. But it does say here that it does qualify for reimbursement if it’s with lab service, which is what your scenario showed.
Learn More about Medical Codes
Preventative CPT Codes – Video
AAPC – 36415 and 85025