Pediatric Coding Alert

Question: How do I code venipuncture for a 3 kg infant under 1 year? I thought I should use 36420, but my colleague says that’s not right, even though the descriptor says the code is for patients under 1 year of age. Which code should I report?

Delaware Subscriber

Answer: Your colleague is correct. Based on the location of the venipuncture, you’ll likely have to choose a code such as:

• 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)

Here’s why:

Code 36420 (Venipuncture, cutdown; younger than age 1 year) describes a procedure where the provider makes an open incision to obtain access to a vein, usually because the patient is so young that the physician cannot obtain intravenous access with a percutaneous stick into the peripheral vein.

However, the child you refer to only weighs 3 kg. 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 to the procedure number.”

You may then think you can simply report 36420 with modifier 63 (Procedure performed on infants less than 4 kg). Unfortunately, CPT^® guidelines instruct you not to report modifier 63 in conjunction with 36420. This is probably because the complexity of the work is already captured in code 36420. You can see this by comparing the work relative value units [RVUs] for the codes: 36420 is valued at 1.01, while 36400-36406 [Venipuncture, younger than age 3 years …] are valued from 0.18 to 0.38.

Takeaway: Finding a vein in an infant is difficult and requires great skill on the part of the provider. The procedure has to be performed by a physician or other qualified healthcare professional (QHP) who can locate a venipuncture in the child’s femoral or jugular vein, scalp vein, or other location. So with 36420 off the table, you’re left with the pediatric venipuncture codes for children under 3 years of age.