Pathology/Lab Coding Alert

Blood-draw services can stick it to you unless your lab follows payer coverage rules. With a new blood-collection code in CPT 2003, now is the time to review phlebotomy coding and reimbursement for your lab.

"Medicare pays labs only for routine venipuncture, and many payers follow suit," says Joan Logue, BS, MT-ASCP, principal with Health Systems Concepts Inc. in Longwood, Fla. Other payers cover both venipuncture and other collection methods, such as capillary draws. But some payers won't pay for blood draws at all because they consider the service bundled with the lab test, Logue cautions.

CPT Codes for specialized blood-draw methods such as arterial puncture describe professional services, and only a physician performing the service can bill for it. That's why understanding the codes is just the starting point you also have to know who can bill and who can be billed for any blood-draw services rendered.

Know Your Punctures From Your Sticks

All blood draws are not created equal you have to differentiate between venous punctures and capillary sticks. Make sure lab personnel know that simply documenting a blood draw doesn't provide the specificity required for coding and reimbursement. Punctures and sticks now require different codes, and payers may cover one but not the other.

"The most common blood draws for many lab tests are either routine venipuncture or 'fingerstick,'" Logue says. CPT 2003 segregates these services into two separate codes for the first time, modifying 36415* (Collection of venous blood by venipuncture) to eliminate fingerstick from the code description and adding 36416 (Collection of capillary blood specimen [e.g., finger, heel, ear stick]) specifically for that service.

Medicare won't pay for fingerstick or similar capillary collection methods, so don't report new code 36416 to Medicare. And if you're billing Medicare for venipuncture, you can't use 36415 even though the service is the same. "Bill Medicare for routine venipuncture using HCPCS Level II code G0001 (Routine venipuncture for collection of specimen[s]) rather than 36415," Logue advises. "Although we had expected Medicare to accept revised code 36415 now that fingerstick was removed from the definition, code G0001 currently remains in effect for routine venipuncture for Medicare beneficiaries."

If you bill Medicare for venipunctures, make sure you also bill private payers for the procedure on non-Medicare patients, Logue says. That way you don't appear to be billing Medicare differently, which could lead to suspicions of fraud and abuse.

"Although they don't pay much, billing for blood draws helps our lab recuperate some of the costs associated with those services," says Stan Werner, MT (ASCP), administrative director of Peterson Clinical Laboratory in Manhattan, Kan.

Professional Blood-Draw Codes Are Different

CPT provides other codes for specialized blood draws such as arterial puncture, but many payers recognize these only as professional services. Medicare, for example, may pay for these codes under the Physician Fee Schedule when the physician performs the draw.

The 36400 family of codes describes venous blood draws from a small child. These codes are 36400 (Venipuncture, under age 3 years; femoral or jugular), 36405* ( scalp vein) or 36406 ( other vein).

Code 36540 (Collection of blood specimen from a completely implantable venous access device) describes withdrawal of venous blood through a catheter. Many payers consider this service bundled with other catheter or lab codes. In any event, do not report 36540 with either 36415 or 36416, according to CPT direction.

For certain tests such as blood gases, physicians may perform an arterial blood draw, which represents a far more complicated procedure than routine venipuncture. You should report this service with 36600* (Arterial puncture, withdrawal of blood for diagnosis) rather than a venipuncture code. When it is provided by a physician, Medicare pays for arterial puncture at nearly 10 times the rate of a routine venipuncture.