I have a dilema that I need some advice from my fellow coders. On a recent coding audit for one of my clinics, the auditor discovered that the clinic was not documenting veinpunctures when patients had labs drawn at the clinic. There was no documentation of the veinpuncture whatsoever. As it turns out, our company policy states that the sites do not have to document the veinpuncture unless there is some sort of problem with the blood draw. When I spoke to our clinical complience department about the policy, it was stated to me that the lab work can't be done without the veinpuncture being performed, so the veinpuncture is implied. Clearly the policy needs to be changed, but my problem here is that these claims went out the door to Medicare. I have researched Medicare criteria and can't find any documentation requirements for veinpunctures. I have a very uneasy feeling about this because I feel that we are billing Medicare for services we can't prove we provided because of no documentation. Before I proceed with a fraud investigation and notify Medicare, I want to make sure that I am doing the right thing here. Is there some guidance from Medicare that I missed about veinpunctures? I want to make sure that I am on target here. Thanks.