Oncology & Hematology Coding Alert

Question: Is there any authoritative guidance on what separates 99195 from 36415?

Answer: The AMA's CPT Assistant explained the different uses for these codes in the June 1996 issue.

As part of the 36400-36425 range, 36415 (Collection of venous blood by venipuncture) is a venipuncture code appropriate when you need to report obtaining blood specimens, the article notes.

The key word to focus on to understand proper use of 99195 (Phlebotomy, therapeutic) is "therapeutic." For example, as CPT Assistant indicates, doctors may order therapeutic phlebotomy for patients with polycythemia vera (238.4, Polycythemia vera) "to reduce the hematocrit and red blood cell mass."

So although staff may refer to a blood draw as phlebotomy, you should not report 99195 unless the service was therapeutic in nature. Clinical documentation should support the service performed.

Watch out: If therapeutic phlebotomy is performed in an inpatient or outpatient setting, the hospital -- not the physician -- should bill it because the hospital provides the space, personnel, and necessary equipment.

Support: The Medicare fee schedule gives 99195 a PC/TC indicator of "5," which identifies it as an "incident to code," according to the "National Physician Fee Schedule Relative Value File Calendar Year 2011." As a result, "Payment may not be made by carriers for these services when they are provided to hospital inpatients or patients in a hospital outpatient department."