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How Do I Code Blood Draw Plus E/M?

Posted on 08. Oct, 2009 by in Coding Challenge, Hot Coding Topics

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...

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