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Bill E/M level and 36540 for drawing blood from venous access device

APCs Weekly Monitor, December 23, 2005

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Bill E/M level and 36540 for drawing blood from venous access device

QUESTION: How do we bill status indicator N procedures when hospital staff performed no other services on the patient? For example, to capture the service 36540 (collection of blood specimen from a completely implantable venous access device) is it appropriate to add the procedure to our E/M system? The nurse encounter form documentation for this procedure is focused on the site, procedure etc.

If we do add it to our E/M system, should we report 36540 separately as well? If we add it in our E/M facility leveling system, and code it separately, it appears as "double" dipping, even though 36540 reported alone generates no separate reimbursement.

ANSWER: CMS in conjunction with the APC Advisory Panel reviewed all status N codes prior to issuing the 2006 OPPS final rule. In the rule CMS stated that the services described by CPT code 36540 are almost always provided in conjunction with other separately payable services in the hospital outpatient department setting. CMS' data does not support the separate payment of this service. CPT code 36540 is also bundled under the Medicare Physician Fee Schedule (MPFS).

As a general rule, the reason CPT codes are assigned an N status is because they are provided in conjunction with another, non-status N code(s) the majority of the time. CMS continues to evaluate N status codes, so it is important that you bill for these services when your facility provides them. Billing for them also allows CMS to more accurately calculate costs associated with payable CPT codes.

In your example, it is appropriate to bill for an E/M visit, provided that the patient is evaluated prior to the collection of blood and is assigned an E/M level based upon your facility E/M criteria. It is also appropriate to bill for the collection of blood, CPT 36540 in addition to the E/M level. Since non-Medicare payers expect you to bill this sole service with 36540 only, it is a challenge to report both the E/M and 36540 to Medicare. This is likely the reason Medicare has little data on 36540 as the sole service.

If possible, divide the price for 36540 in half. Bill the E/M with one half of the usual charge for 36540, and bill 36540 with the other half. For example, if a nurse performs this procedure only and you charge $100 for it, to bill Medicare split the charge and bill a level one E/M visit (99211) with $50, and $50 for code 36540. For all other payers, bill $100 with 36540 as the only code reported. That way, you would bill all payers the same charges/dollars for the same service. You would also be reporting it in the manner Medicare desires.

We also encourage providers to submit clinical examples to CMS or to the APC Advisory Panel. This information will hopefully increase recognition of 36540 as a separately payable service, and given enough data CMS may reimburse for it separately in future years -- similar to the bladder catheterization codes that are assigned separate APC payment beginning January 1, 2006.

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