# 36415 documentation



## donnaber (Apr 27, 2011)

Hello all, 

I'm looking for CMS, Noridian, trailblazer or any reputable source for venipuncture (36415) documentation requirements. Thanks so much


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## alincoln (Nov 29, 2011)

I am looking for the same guidance, but for Palmetto MAC... but any guidance would be helpful as Palmetto doesn't have an LCDs/policies published for this.
Have you found anything?
Thanks!


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## ajs (Nov 29, 2011)

donnaber said:


> Hello all,
> 
> I'm looking for CMS, Noridian, trailblazer or any reputable source for venipuncture (36415) documentation requirements. Thanks so much



I don't believe there are any specific documentation requirements for a simple blood draw.  In many cases it is included in whatever other services are provided.  CMS does not provide documentation requirements on this type of service.


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## alincoln (Nov 29, 2011)

Thanks Arlene!

What if that is the only service provide that day?  We have patients coming in just for blood draws with the MA and nothing else?  Shouldn't that be documented in some way?


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## ajs (Nov 29, 2011)

alincoln said:


> Thanks Arlene!
> 
> What if that is the only service provide that day?  We have patients coming in just for blood draws with the MA and nothing else?  Shouldn't that be documented in some way?



Yes, they would document venipuncture and what site.  Just standard documentation for doing a blood draw, similar to documenting an injection.


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## alincoln (Nov 30, 2011)

Thanks Arlene!!!


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