Lab Draw 36415 or 36416

MAWK

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Montezuma Creek, UT
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In order to bill for a lab draw is there documentation needed from a lab tech regarding what what done? I work in a family practice facility and sometimes there is documentation from the lab tech and times there is no notes but the lab reports are all filed in the patient chart.
 
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In order to bill for a lab draw is there documentation needed from a lab tech regarding what what done? I work in a family practice facility and sometimes there is documentation from the lab tech and times there is no notes but the lab reports are all filed in the patient chart.
In our practice if a patient has lab done during an office visit whomever draws or does fingerstick documents done and their initials. The reason we do this is if the blood is sent to our outside lab we do not always bill for the lab tests (depends on insurance carrier) and by them doing the simple done---abc lets us know that blood was actually drawn.
If the patient comes in just for a blood draw only then a lab only note is created and the lab tech/nurse documents what provider ordered lab, what tests are being ordered and they indicate how blood was obtained.
 

MAWK

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Montezuma Creek, UT
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I was asking because we had our charges audited and I was told I didn't have the 36415 or 36416 on my charges. I didn't add those codes on the charges because there were no documentation from the lab tech but now I am adding those codes and it seems like I shouldn't be adding lab draws if there are no documentation to support it.
 
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I was asking because we had our charges audited and I was told I didn't have the 36415 or 36416 on my charges. I didn't add those codes on the charges because there were no documentation from the lab tech but now I am adding those codes and it seems like I shouldn't be adding lab draws if there are no documentation to support it.
In my opinion you were correct for not billing because you didn't know how the blood was obtained, like we have always been taught, if it's not documented it didn't happen. The lab tech needs to document how blood was obtained in order to know which charge to bill for (36415 or 36416). You might want to get with the clinical manager or whomever is over the lab to develop a policy & procedure regarding documenting blood draws.
 

thranowski

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Orlando, FL
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In my opinion you were correct for not billing because you didn't know how the blood was obtained, like we have always been taught, if it's not documented it didn't happen. The lab tech needs to document how blood was obtained in order to know which charge to bill for (36415 or 36416). You might want to get with the clinical manager or whomever is over the lab to develop a policy & procedure regarding documenting blood draws.

In addition to this, at our practice when the nurse chooses the lab, it automatically adds 36416 or 36415 depending on the test ordered and it carries over into the encounter note. If that is an option for this office to make things foolproof.
 

MAWK

Networker
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Montezuma Creek, UT
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Let me ask you another question is it for the x-ray example left hand was x-ray and I linked that x-ray to left hand injury but the auditor noted I didn't add modifier LT.
 
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Let me ask you another question is it for the x-ray example left hand was x-ray and I linked that x-ray to left hand injury but the auditor noted I didn't add modifier LT.
From experience it's going to depend on the insurance carrier. With diagnosis codes now indicating laterality most carriers don't require the use of LT/RT modifiers as long as the diagnosis used indicates left or right.
 
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