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Wiki Phlebotomy documentation

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shruthi

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What should be the documentation requirement for Phlebotomy when the blood test are ordered during the office visit. Should the details of blood draw be documented in separate report or it can be documented in the plan section of office visit report?
 
In order to capture an accurate code for the blood draw, you'll need to know exactly how they took the specimen. (via Vein, Port, Finger Prick, etc.) The most common code that I see with a blood draw is 36415, but I would never assume. That is if you're wanting to code for the blood draw.

If you're wanting to code for the lab itself, then you can go from what lab was completed.
 
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