Resolved 36415

[MistyR_46049]

For the facility if a phlebotomist or nurse do the venipuncture, I am trying to find the supportive documentation of what needs to be documented to bill 36415. Or if its another method or way to get it drawn. I could not locate anything on CMS but thought I would ask. THanks
•Was this a vein or capillary draw?
•What tools were used (i.e. cath, venous access device, butterfly needle, etc…)?
•What part of the body was the sample obtained from (i.e. left/right arm, leg, foot, etc…)

 

[Alicia]

I did find this article from Medical Economics Journal. It is tells you how to document and bill for a venipuncture. Note, it most likely will not get paid as it is usually bundled. Another place to look is nursing guidelines for documentation.

How to properly document and bill for venipuncture

Keep these tips in mind when documenting and billing for venipuncture.

www.medicaleconomics.com

 

[MistyR_46049]

I was just looking for what documentation is needed by the phlebotomist to bill 36415, Like site, vein or location etc that sort of thing for medical necessity

 

[Alicia]

Here is what is needed:

1. Patient Information:
   • Full name of the patient
   • Date of birth
   • Gender
   • Patient identification number or medical record number
2. Date and Time:
   • The date and time when the venipuncture was performed
3. Ordering Physician:
   • Name of the physician who ordered the venipuncture
4. Procedure Details:
   • Description of the venipuncture procedure
   • Any specific details related to the procedure
5. CPT Code:
   • Current Procedural Terminology (CPT) code for venipuncture. Common codes include 36415 for routine venipuncture.
6. Diagnosis Code:
   • International Classification of Diseases (ICD) code indicating the medical reason for the venipuncture
7. Documentation of Consent:
   • If required, documentation that the patient provided informed consent for the procedure
8. Lab Requisition:
   • Details of the laboratory tests requested by the physician
9. Phlebotomist's Signature:
   • Signature or identification of the phlebotomist who performed the venipuncture
10. Location:
    • The location where the venipuncture was conducted, such as the clinic or hospital name

 

[MistyR_46049]

Perfect, do you have a link that says that? Like CMS or AAPC or AHIMA etc for audit purposes?

 

[Alicia]

You can Google it. Just type: Documentation needed for a venipuncture.
Here is one site that came up: https://wtcs.pressbooks.pub/nursing...mentation Cues:,time, and blood samples drawn

 

[MistyR_46049]

Thanks