Get to the Bottom of Venipuncture Performed in the Office
36415 is a laboratory service and should be billed as such.
Physicians often provide routine venipuncture to patients when ordering a laboratory test to save the patient a trip to the laboratory. This service is reported with CPT® 36415 Collection of venous blood by venipuncture. Although reimbursement is only $3, the Centers for Medicare & Medicaid Services (CMS) audits this code, and frequently recoups funds paid to providers in error.
Remember the Rules when Billing
To bill correctly, understand that 36415 is considered to be a laboratory service, and is listed on the CMS Laboratory Fee Schedule (even though it is found in the Surgery/Cardiovascular System section of the CPT® codebook). For this reason, reporting 36415 requires an ordering physician and a written order, as do all laboratory services.
A physician or qualified non-physician practitioner must sign an order (or a progress note supporting intent and medical necessity) specific to the patient, noting what specific tests were ordered. According to CMS Comprehensive Error Rate Testing (CERT) reviews, “An attestation statement is not acceptable for unsigned orders. If a valid order or progress note is not submitted to support the intent for the laboratory services performed, the related venipuncture will be denied as not medically necessary.”
Diagnosis coding for 36415 must support the tests to be performed based on the venipuncture. Medicare does not cover venipuncture for routine diagnoses (for example, Z00.00 Encounter for general adult medical examination without abnormal findings).
When to, and When Not to, Use an ABN
If there are no covered diagnoses, the patient should be informed with an Advance Beneficiary Notice (ABN) so he or she understands the service may not be covered and that he or she will be responsible for the venipuncture, as well as the laboratory fee from the outside laboratory. The office must bill with modifier GA Waiver of liability statement issued as required by payer policy, individual case to indicate the patient was informed and the patient signed the ABN.
When multiple entities render care, Medicare does not require you to issue separate ABNs. Any party involved in the delivery of care can issue the ABN when there are separate ordering and rendering providers (for example, a physician orders a laboratory test and an independent laboratory delivers the ordered tests). For more information, see Medicare Learning Network’s® “Advance Beneficiary Notice of Noncoverage (ABN).”
Clearly Indicate an Order
“Standing orders” for a patient are allowed if the frequency is appropriate and necessary for a patient’s clinical circumstances. If there is no order in the patient’s chart, the patient needs to have one documented prior to the venipuncture.
For example: The patient stops by the office because he knows it’s time for his regular laboratory tests, but there is no indication in his record that he is to return to the office for periodic retesting. Because there is no order in place, the venipuncture would not be covered under Medicare.
The lesson here is that each test result must be reviewed, with appropriate action taken by the treating physician, and these actions must be documented in the patient’s record.
Don’t Use 99211 with Venipuncture-only Services
Never report 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services for a patient encounter that involves only venipuncture. CPT® 99211 is an evaluation and management (E/M) service commonly used for patient education, simple rechecks, and medication reviews.
More CERT Errors for CPT® 36415
As per WPS Medicare, J8 Part B, some examples of CERT findings:
Laboratory test(s) were not medically necessary for lack of the verification of treating physician’s order(s), and lack of progress notes for medical necessity/reason for ordering specified test(s); therefore, venipuncture was denied as not reasonable and necessary.
The CERT contractor received physician-signed attestation statement as an acknowledgment to Prothrombin time and drawn thyroid stimulating hormone (TSH). Attestation for orders are not accepted; only the physician signature attestation statements are valid. All diagnostic services require a signed physician order (or signed progress note supporting intent) and documentation of medical necessity to be payable by Medicare. An attestation statement is not acceptable for unsigned orders. If a valid order or progress note is not submitted to support the intent for the laboratory services performed, the related venipuncture will be denied as not medical necessary.
Medicare Learning Network®, “Advance Beneficiary Notice of Noncoverage (ABN),” Fourth Edition, August 2014: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/ABN_Booklet_ICN006266.pdf
WPS Medicare, J8 Part B, second quarter 2015 (April – June) – CERT Error Summary: www.wpsmedicare.com/j8macpartb/departments/cert/2015-2nd-quarter-error-summary.shtml
WPS Medicare, J8 Part B, Recognizing the Meaning of “Standing Orders:” www.wpsmedicare.com/j8macpartb/departments/cert/recognizing-standing-orders.shtml
LuAnn Jenkins, CPMA, CPC, CEMC, CFPC, is president of MedTrust, LLC, a practice management Michigan-based consulting firm. She has spoken on coding and reimbursement issues for the Michigan State Medical Society and is past president of the Michigan Medical Billers Association. She was 2006 AAPC Coder of the Year. Jenkins is a member of the Grand Rapids, Mich., local chapter.