Pediatric Coding Alert

Age, weight, technique, and provider qualifications key to correct code capture.

If your practice has a lab associated with it, blood draws are among the most common procedures performed in your office. But venipuncture coding is far from common. Variables such as technique and the qualifications of the provider performing the procedure all come into play when it comes to assigning the most appropriate CPT^® code.

But factors such as the patient’s age and weight also factor into code determination. So, to clear up any confusion, we put together this brief guide to the venipuncture codes. Read on. We promise it won’t hurt a bit.

Know Your Definitions

The first important step in coding for venipuncture is knowing the difference between two terms that are frequently — and incorrectly — used interchangeably.

Phlebotomy is a broad term, which refers to the opening of a vein to remove blood for any reason. “Venipuncture,” on the other hand, “is a subset of phlebotomy, which refers to the use of a needle to puncture a vein from which to collect blood into a syringe or evacuated tube,” explains Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

This explains why CPT^® assigns a separate code, 99195 (Phlebotomy, therapeutic (separate procedure)), for phlebotomy, and specifies the procedure is for therapeutic, and not diagnostic, purposes. For blood collection solely for diagnostic purposes, the most common codes are 36416 (Collection of capillary blood specimen (eg, finger, heel, ear stick)) and the routine venipuncture code, 36415 (Collection of venous blood by venipuncture).

Then Factor in Patient Age, Provider, Location, or Technique

For older patients, the process of inserting a needle percutaneously into a peripheral vein to obtain blood — usually the median cubital vein where the arm bends at the elbow — is relatively straightforward, as such veins are prominent and easily located. For younger patients, however, percutaneous puncture of a vein with a needle is not always an option, as finding a vein is difficult and requires great skill on the part of the provider.

For this reason, CPT^® includes several other codes describing venipuncture that either requires the skill of a physician or other qualified healthcare professional (QHP) or that requires a technique known as a cutdown, which is more complex than inserting a needle into a vein.

For venipuncture requiring a physician’s or QHP’s skill: If the patient is 3 years or older, you’ll use 36410 (Venipuncture, age 3 years or older, necessitating the skill of a physician or other qualified health care professional (separate procedure), for diagnostic or therapeutic purposes (not to be used for routine venipuncture)). This means your documentation for 36410 “must show that a doctor or other QHP performed the service, and that clinical conditions were such that only doctors or QHPs, and not clinical staff, could do so,” cautions Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

In this instance, a physician or other QHP is “an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service,” per CPT^® guidelines. This would include such providers as physicians, physician assistants (PAs), and nurse practitioners (NPs). A clinical staff member, however, is “a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service,” according to CPT^® guidelines. This would include, but not be limited to, registered nurses (RNs) and licensed practical nurses (LPNs).

For patients younger than three, code choice is broken down further. While the procedure still has to be performed by a physician or other QHP, code choice is dependent on the anatomic location of the venipuncture. You have three sites to choose from:

• 36400 (Venipuncture, younger than age 3 years, necessitating the skill of a physician or other qualified health care professional, not to be used for routine venipuncture; femoral or jugular vein)
• 36405 (… scalp vein)
• 36406 (… other vein)

For venipuncture requiring a cutdown procedure: Here, you have the choice of two age-specific codes — 36420 (Venipuncture, cutdown; younger than age 1 year) and 36425 (… age 1 or over).

Then Mind the Use of This Modifier

According to Appendix A of CPT^®, “Procedures performed on neonates and infants up to a present body weight of 4 kg may involve significantly increased complexity and physician or other qualified health care professional work commonly associated with these patients. This circumstance may be reported by adding modifier 63 [Procedure performed on infants less than 4 kg] to the procedure number.”

So, before you assign a venipuncture code, make sure you double-check the patient’s age and weight, and add modifier 63 when appropriate.

But note this exception: Per the CPT^® instructional note that accompanies 36420, you will not report modifier 63 with this particular procedure. “This is likely because the increased complexity and physician/QHP work represented by modifier 63 is already captured in code 36420,” Moore notes.

You can see this by comparing the national non-facility fees for the codes. Currently, 36420 is valued at $48.10, while 36400-36406 are valued from $28.03-$17.65.