Wiki CPT 36415 - Is provider sign off required?

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Jan Klawitter

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Hello! I hope someone has an answer to my question. I work for a large medical group that is part of a managed care network. This question came up today and here is the scenario. A patient presents for lab work and a blood draw (CPT 36415) is performed. The patient is not seen by a nurse or a provider, but is only seen by the phlebotomist. Since CPT 36415 is considered a procedure, to be in compliance does any governing authority require the blood draw to be signed off?
jan.klawitter@yahoo.com
 
I'm not aware of any official regulation or payer policy requiring a provider signature for this procedure, though some organizations may have internal policies that require it. In my opinion, it would not serve any real purpose and would be a waste of a physician's time to have them do this. 36415 is a simple and routine procedure that doesn't require a physician's participation so I don't see that it adds any information of value to have a physician's signature. And with a value of around $3.00, no payer is going to go through and audit your records for a missing physician signature for this procedure - it would cost them more to do that than the amounts they would be able to recover.
 
thomas7331 said:
I'm not aware of any official regulation or payer policy requiring a provider signature for this procedure, though some organizations may have internal policies that require it. In my opinion, it would not serve any real purpose and would be a waste of a physician's time to have them do this. 36415 is a simple and routine procedure that doesn't require a physician's participation so I don't see that it adds any information of value to have a physician's signature. And with a value of around $3.00, no payer is going to go through and audit your records for a missing physician signature for this procedure - it would cost them more to do that than the amounts they would be able to recover.
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Thank you so much for your response and I agree. However, I need to find documentation to support that a sign off is not required.
 
Jan Klawitter said:
Thank you so much for your response and I agree. However, I need to find documentation to support that a sign off is not required.
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Understood, but you may have difficulty finding such documentation - regulatory bodies generally publish documentation detailing what they do require, not what they don't. But you might want to consider submitting your question to your Medicare contractor in order to get a written response that you can keep on file.
 
thomas7331 said:
Understood, but you may have difficulty finding such documentation - regulatory bodies generally publish documentation detailing what they do require, not what they don't. But you might want to consider submitting your question to your Medicare contractor in order to get a written response that you can keep on file.
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thomas7331 said:
Understood, but you may have difficulty finding such documentation - regulatory bodies generally publish documentation detailing what they do require, not what they don't. But you might want to consider submitting your question to your Medicare contractor in order to get a written response that you can keep on file.
Click to expand...
Excellent idea. Thank you!
 
Hi Jan
At my facility or doctor's office if patient gets blood drawn CPT 36415 . The provider / doc will order lab test on a requisition order form in which he wants to check if pt. has a certain disease. The doctor has to sign out the orders somewhere on the pt.s medical record & requisition lab form. Sometimes doc tell nurse draw the blood and it is sent to lab and billed to pt insurance then results sent to doctor/provider to later inform the result to the pt. For instance if checking for Diabetes may order test 80053 WBC or 81003 Urinalysis then add dx code R73.03 and Z13.89 on lab order. Also the doc would inform the lab this when pt arrives. The physician HAS to order the blood draw for a type of lab or it cannot happen. Lab business will not complete the lab test if not ordered properly by a doctor who gives a diagnosis code to support reason for blood test which is billed to the insurance payer. The CLIA reg may talk about this too
I hope this data helps you.
Lady T:)
 
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