Internal Medicine Coding Alert

Question: We have a repeated discussion in our office about whether we can bill 36415 (Collection of venous blood by venipuncture) for a medical assistant working under a physician when the physician isn't in the office. Can you settle the issue for us?

Nevada Subscriber

Answer: The guidelines associated with 36415 don't state that a physician must be present when the staff member provides the service (whether a nurse, medical assistant, or other professional). Because of this, you can document and code for venipuncture represented by 36415 even if the physician isn't in the office at the time of the draw.

Not incident-to: Your staff person who believes the physician must be present during the blood draw might be thinking of following incident-to guidelines for certain services. Medicare considers a blood draw as part of the clinical laboratory services. Lab tests have their own benefit category under Medicare, so are not subject to incident-to guidelines.