Wiki 36410 "Published Diagnosis"

cindyssmilin

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Local Chapter Officer
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We have a pediatrician who is billing 36410 alone when she needs a glucose test. No office visit, no lab charge. The diagnosis code she is using is 790.29. Our Medicaid HMO is denying the charge stating that we are not using the published diagnosis per CMS guidelines. I cannot find an LCD or NCD regarding this. Anyone have a clue?

All help is greatly appreciated.

Thank you in advance!
Cindy
 
I'm not sure where you live, but I have found a couple LCD from across the US (Ohio and Kentucky) with exact or similar language to this:

"Submit CPT code 36410 only for venipunctures necessitating physician skill when performed by a physician on veins of the neck, (e.g., external or internal jugular), or from deep (central) veins of the thorax (e.g., subclavian) or groin (e.g., femoral); and for venipuncture of superficial extremity veins when the skill of a qualified individual properly trained in venipuncture techniques (e.g., nurse, phlebotomist, medical technician) has been clearly demonstrated, according to the terms of this policy, to be insufficient. ICD-9-CM 459.89 or V49.5 must be submitted on all claims for CPT 36410."

I would also add that just becaunse the physician is performing the venipuncture it does not mean that it "required the skill of a physician" as 36410 states. It sounds like 36415 - routine venipuncture - might be a better code choice unless your documentation supports the use of 36410.

Hope this helps.
 
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