Primary Care Coding Alert

Here’s all you need to know about blood draws. And it won’t hurt a bit.

There’s an awful lot of confusion over the codes that describe the relatively basic procedure of a blood draw. But if you understand three expert coding principles, you can bust a bunch of venipuncture myths quickly and easily.

Here’s how.

All You Need to Know About 36400-36425 (and 99195) but Were Afraid to Ask

To use the venipuncture codes correctly, all you need to do is “ask three things. First, does the services require the skills of a physician or qualified health care professional [QHP]? Second, does it match the age of the patient? And third, is the service really venipuncture or some other form of blood collection?” advises Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Get the answers to these three questions correct, and you’ll be well on your way to busting these common myths surrounding the codes.

Myth 1: The only difference between 36410 and 36415 is who can perform them.

This first myth is only partly true. While one important difference between 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)) and 36415 (Collection of venous blood by venipuncture) is indeed the qualification necessary for the provider performing the procedures, there are other important differences that explain why that qualification is a significant component of the service.

For while both codes can be used to draw blood for diagnostic purposes, only 36410 can be used if the procedure is for therapeutic services. “This implies venipuncture done for other purposes (e.g., screening) should be reported with 36415 rather than 36410,” says Moore.

It also explains why the descriptor for 36410 states the procedure is “not to be used for routine venipuncture.” This is because the procedure is more medically complex than 36415, which then explains why the procedure must be performed by a physician or other QHP.

Coding alert: CPT^® guidelines define a physician or other QHP as “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.” This would include such providers as physicians, physician assistants (PAs), and nurse practitioners (NPs).

However, CPT^® defines a clinical staff member as “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.” This would include, but not be limited to, registered nurses (RNs) and licensed practical nurses (LPNs).

This means your documentation for 36410 “must show that a doctor, PA, NP, or other QHP performed the service, and that clinical conditions were such that only QHPs, and not clinical staff, could do so,” Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania reminds coders.

Myth 2: You can use 36420 with any infant under 1 year.

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.

Even though the code descriptor states that a provider can perform the procedure on children under the age of 1, CPT^® guidelines instruct you not to report modifier 63 (Procedure performed on infants less than 4 kg) in conjunction with the code.

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.”

So, even if the child is under 1 and weighs less than 4 kg, you cannot append modifier 63 to the code. “This is likely because the increased complexity and physician/QHP work represented by modifier 63 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,” Moore notes.

Why? Not all infants under 1 year require cutdown venipuncture. For some infants, percutaneous puncture of a vein with a needle is an option, but finding a vein is difficult and requires great skill on the part of the provider. That mean, like 36410, the procedure has to be performed by a physician or other QHP who can locate a venipuncture site in the child’s femoral or jugular vein (36400), scalp vein (36405), or elsewhere (36406).

Coding alert: Make sure that your provider documents the anatomic location of the venipuncture to report the correct code in such circumstances.

And remember this: CPT^® guidelines also instruct you not to report modifier 63 with 36415.

Myth 3: You can use 99195 for routine venipuncture.

The myth here stems from confusion over the terms “phlebotomy” and “venipuncture,” which are often used interchangeably. However, this is incorrect. Basically stated, “venipuncture — using a needle to puncture a vein from which to collect blood into a syringe or evacuated tube — is a subset of phlebotomy, which is a broader term referring to the collection of blood by one of several methods, some of which — arteriopuncture, for example — are not venipuncture,” says Moore.

This explains the important difference between 36415 and 99195 (Phlebotomy, therapeutic (separate procedure)). Like 36410, “99195 is a separate procedure that can also be used for therapeutic purposes, which includes reducing hematocrit and red blood cell mass in the treatment of polycythemia vera and other diseases,” says Falbo. This means “you should not use the 99195 for routine blood draws. Instead, you should use 36415,” Falbo cautions.

The final word: “Some of the codes include the parenthetical phrase ‘separate procedure.’ That means they can only be reported when they are performed as a separate procedure. If they’re done as an inherent part of a larger procedure that’s also being reported, then the venipuncture cannot be separately reported,” Moore concludes.