Oncology & Hematology Coding Alert

Follow this advice to be sure your EHR isn't setting you up for trouble.

Electronic health record (EHR) documentation templates can be a blessing and a curse.

Case in point: If your system doesn't prompt clinicians to document the method of a blood-draw, auditors may decide documentation fails to support your code choice for the procedure. Steer clear of this trap with expert insights into the documentation you need and how you can be sure you get it.

See How Method Matters for Code Choice

Before EHRs (also called EMRs or electronic medical records) took hold, labs typically had a collection log where they would document how and at what site a specimen was drawn. Now, an EHR may provide the information for a venous blood draw. It may neglect, however, to tell you what method was used for the draw.

For example, the EHR may show: "Specimen: blood, Drawn: at 1pm, By: Suzie Q (user)."

Problem: What is missing is how staff obtained the venous blood specimen. Venipuncture may be the most common collection method, but it certainly isn't the only one.

Code connection: "Coding follows documentation, so selecting the correct code depends upon having the proper documentation of the method of the blood draw, whether it is by venipuncture, implanted port, PICC line, etc.," says Lisa S. Martin, CPC, CIMC, CPC-I, chargemaster specialist for OSF Healthcare System in Peoria, Ill.

The following list of codes demonstrates how blood-draw coding varies by method:

• 36400-36410 -- Venipuncture ... necessitating physician's skill ...
• 36415 -- Collection of venous blood by venipuncture
• 36416 -- Collection of capillary blood specimen (e.g., finger, heel, ear stick)
• 36420-36425 -- Venipuncture cutdown ...
• 36591 -- Collection of blood specimen from a completely implantable venous access device
• 36592 -- Collection of blood specimen using established central or peripheral catheter, venous, not otherwise specified.

Payers reimburse separately for some of the above methods and consider others to be included in other services performed the same day. When claiming a service for reimbursement, be sure you've got the supporting documentation to back up your choice, no matter how minimal expected reimbursement may be. Venipuncture may reimburse at a very small amount, but the volume of this procedure in most practices and facilities is enormous, which makes proper coding worth your while.

Straight From the Payer: A Documentation Must

If your practice has a policy of assuming 36415 is the proper code unless otherwise stated, or if you believe that 36415 is appropriate as long as there's a lab result, be warned. A payer performing an audit may want to see proof of method before it agrees you deserve to keep 36415 payment.

For example: In a Frequently Asked Question post, last reviewed Feb. 15, 2011, Palmetto replied to the question: "When submitting a venipuncture for medical review, what documentation is required?"

Palmetto's reply is: "The documentation must clearly reflect the venipuncture had been performed. Laboratory results alone are not sufficient to document that venipuncture was performed."

Resources: Palmetto's Jurisdiction 11 Part B providers (South Carolina, North Carolina, Virginia, and West Virginia) can find the J11 FAQs by going to www.palmettogba.com/palmetto/providers.nsf/DocsCatHome/Jurisdiction%2011%20Part%20B and selecting "Frequently Asked Questions" under "Self Service Tools."

Palmetto's Ohio Part B providers can follow the same instructions, but should start at this link: www.palmettogba.com/palmetto/providers.nsf/DocsCatHome/Ohio%20Part%20B%20Carrier.

Takeaway: The issue of venipuncture documentation seems to be gaining the attention of CMS. Regardless of which payers you send claims to, be sure your practice has policies and procedures in place to ensure proper documentation so you can support your coding when needed.

Find the Solution That Works for Your Practice

If your EHR doesn't prompt the provider to document the method of the blood draw, there are steps your practice can take to be sure documentation is at the level you need it to be.

"There is definitely a difference between EMRs and their capabilities, but there is almost always an option for thenurse or phlebotomist to be able to 'free-text' a note or to be able to scan a document that can be retrieved and viewed," says Martin.

Documentation do: "All care rendered to the patient should be documented, and although a minor procedure, blood draws are still an invasive procedure that should be documented," says Martin.

For instance, implanted ports and PICC line sites are susceptible to complications and infection, Martin notes. So staff should evaluate them each time they access them. "Evaluating that the site is free of swelling/redness/signs of infection and good blood return are just a few of the qualities" that the clinical team should consider for documentation, she says.

Another consideration for good patient care: Phlebotomists dream of prominent, easy to find (bouncy) veins, but may often encounter deep, "thready," "floating," or thrombosed veins, which are much more difficult to work with. They could result from a chronic condition or body habitus. Having historical draw information in the patient's medical record can lend some important insight into the best approach when obtaining the sample, lessening the pain, risk, and potential complications.

Smart move: "Regardless of whether your EMR is stateof- the-art or offers very basic features, each office should establish how and where these services are documented. While it may not be easy, with the proper policies and procedures in place, clear and concise documentation can still occur even when dealing with system limitations," Martin says.