CPT 36000


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Good Afternoon,

I was trying to do a little more research on CPT 36000. I was recently audited and we found out some valuable information, on this code. I just was trying to figure out if need to change some procedure wording in our system. I work for an urgent care, and this patient we were getting ready to send them to the ER for higher level of care than we could provide. We started an IV line, but only withdrew blood from the line to run our Chem 8 tests. Then our standard template our providers use for the procedure states that we flush line, but no saline or meds were given. When I started we were told if that was the case we just bill the venipuncture 36415, since we had the required documentation to bill that. Well on this audit through a new company, they stated I should bill 36000 instead of the 36415. What are the generally guidelines to bill 36000? Here is what the template states, "

"The patient was prepared for the procedure by ensuring the appropriate identification and selecting the appropriate equipment. Verbal consent was obtained from the patient after discussing risks, benefits and alternatives to IV placement.

Following the selection of an appropriate location for venipuncture, the skin was cleansed with Chlora-prep prior to the procedure and universal precautions and sterile technique were maintained throughout the procedure. After temporary application of a tourniquet proximal to the venipuncture site, an/a 20 gauge angiocath was inserted into the leftforearm in typical fashion without complication. After withdrawal of the needle, blood was drawn from the angiocath and all specimens were appropriately labeled. The tourniquet was removed and the IV was secured and placement was checked with a saline flush. Universal precautions were maintained throughout the procedure.
The procedure was performed by the Medical Tech under the direct supervision by the APP. After proper IV tube flushing, noted to flush without evidence of infiltration. A Tegaderm dressing was applied. The procedure was well tolerated by the patient. :"

Thank you for your time.