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Wiki 36415 documentation

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donnaber

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Hello all,

I'm looking for CMS, Noridian, trailblazer or any reputable source for venipuncture (36415) documentation requirements. Thanks so much
 
I am looking for the same guidance, but for Palmetto MAC... but any guidance would be helpful as Palmetto doesn't have an LCDs/policies published for this.
Have you found anything?
Thanks!
 
donnaber said:
Hello all,

I'm looking for CMS, Noridian, trailblazer or any reputable source for venipuncture (36415) documentation requirements. Thanks so much
Click to expand...

I don't believe there are any specific documentation requirements for a simple blood draw. In many cases it is included in whatever other services are provided. CMS does not provide documentation requirements on this type of service.
 
Thanks Arlene!

What if that is the only service provide that day? We have patients coming in just for blood draws with the MA and nothing else? Shouldn't that be documented in some way?
 
alincoln said:
Thanks Arlene!

What if that is the only service provide that day? We have patients coming in just for blood draws with the MA and nothing else? Shouldn't that be documented in some way?
Click to expand...

Yes, they would document venipuncture and what site. Just standard documentation for doing a blood draw, similar to documenting an injection.
 
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