Wiki Clarification between billing a 36410 vs 36415 for Medicare, Medicaid and Commercial

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encomma-watson

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My PA (Practice administrator) seems to feel that I should bill 36410 instead of a 36415 because of the reimbursement value, but I want to bill what is correct and she just does not get it, what should I do? Is there a written guideline to this?

Elizabeth Comma-Watson, CPC:confused:
 
36410 is for the physician to perform the venipuncture, and the necessity for that would need to be clearly documented. You may not have the physician routinely performing the venipuncture just for the reimbursement. The patient's condition or special circumstance would be what would justify this and that would need to be clearly reflected in the medical record. The use of the 36410 should be the exception not the norm.
 
You may end up in the fraud department

This code is something that you just don't see a lot because it is usually not necessary for the physician to perform a venipuncture. I am a coding review nurse for a payer and I might submit a provider to the fraud department for review if I saw continual submissions of 36410 without a clear medical indication being documented in the record. Maybe this will convince your boss?????

Good luck! :D

***************************
PB
 
When the office manager instructs to bill a code that is not documented due to reimbursement value, then that is billing for bucks and it is fraud. Not a pretty word but there is no other that fits the description.
 
36410

All the above are correct. There is also further clarification in CPT in the guidance of 36410 It says (not to be used for routine venipuncture). Here's what CPT assistant has to say:

Venipuncture
CPT Assistant, May 2001 Page: 11 Category: Coding Consultation
Related Information
Cardiovascular System

Question

My physician performs a venipuncture for a patient after a previous attempt by an RN to access the vessel was unsuccessful. Should code 36410*, Venipuncture, child over age 3 years or adult, necessitating physician's skill (separate procedure), for diagnostic or therapeutic purposes. Not to be used for routine venipuncture., be used to identify this service?

AMA Comment

Code 36410 would be reported if a routine venipuncture, usually performed, for example, by a nurse or phlebotomist, is unsuccessful and the skill of the physician is required to perform the procedure. In this case, it is no longer a routine venipuncture. It would not be appropriate to report code 36410 if the physician performs the venipuncture merely because the nurse, phlebotomist, or other health professional is unavailable to perform the service.




CPT Assistant © Copyright 1990–2009 American Medical Association. All Rights Reserved
 
Thank you

Thank you all for your answers. I have been billing 36415 and have been getting paid for it. I had to prove to my administrator that 36410 is only used if the md goes in a does the venepuncture himself. We actually got a denial from Medicare and Medicaid for using it. The only time that I do use 36415 is when we do not have a phlebotomist on site.

Thank you all for your answers.
 
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