Documentation for 36416


New Braunfels, TX
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Does there need to be documentation of the capillary blood draw in the chart note to bill for code 36416?

We have OB pt's that come in for their first trimester screening and are having a finger stick, but there is no documentation of this. When I was a MA, we had to document the finger stick when we did it. (ie; capillary blood draw right ring finger on 07/27/2016 at 10:30 am.)

I feel that if it was not documented, then we cannot bill code 36416.

Any thoughts on this?
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I'm not 100% on this, but I'd be inclined to lean towards the good old "if it's not documented, it wasn't done" also.


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I'm catching up on the monthly magazines from AAPC and ran across this from January's issue, page 18. It's on 36415 and not 36416, but their both considered labs.

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.”

That being noted, I do have nurses or office assistants put in their progress note for the patient's encounter. With the EMR, all they have to do is open the encounter where the order is pulled in and chart.
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