Wiki EMR Documentation Issue

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AB87

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When Billing for 36415 (Venipuncture) can someone please show me some clear guideline on how its supposed to be documented. The EMR they use just says
Venipuncture- [36415] and thats it??? Im pretty sure you are supposed to say where/how it was done. Because now a days EMR allows you to plug in anything!! :eek::confused:
 
it is best if this is documented similar to a procedure note, stating who performed the service and at what time and what location on the body the blood was drawn from. This is just good documentation and CYA in case there are issues later.
 
Thank You, I pretty much said the same thing but they want a "Medicare Guideline" for this. They want something that is black & white not a grey area. I really do appreciate your responses and you always give the best Advice!!:D
 
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search the Medicare website for procedure documentation, that should do it. 36415 is a code in the surgical section so you can argue it requires a procedure note the same as any other "surgical" procedure.
 
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