Question Venipuncture documentation


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Hi - We recently switched to a new EHR, and I'm a little wary that the way venipunctures (36415) and finger sticks (36416) are being documented is insufficient. The system is designed so that whoever collects the sample goes into the order for each test and indicates the specimen source (either "blood venous" or "blood capillary") along with collection date and time and the assigned username of the person who collected the sample.
In our old system, we had a template with date, time, site, which tubes were drawn (for veni), whether the patient was fasting (if known/also for veni), the name of the person collecting, and whether or not the patient tolerated the procedure with no reaction. I remember developing this years ago on the advice of a compliance consultant, but I don't have any of the resources they provided anymore. Now I'm having a hard time finding any clear guidance on what documentation is required to support these codes. I want to trust that the EHR developers know what they're doing, but I have a nagging doubt in the back of my mind - and with Cigna's impending requirement for documentation to support the use of the -25 modifier I really want to confirm whether or not what we're doing is sufficient. That said, I also don't want to give our lab staff and nurses additional work if I don't have to.
Long story short (too late), does anyone have any resources that indicate what documentation is required for 36415 and 36416, or any advice to point me in the right direction?
Thanks so much!


True Blue
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I do not have an answer to your question, but do want to comment that the minimum requirements in order to bill the service could be different than what you SHOULD document from a compliance/legal perspective. For example, it may not be required to document "patient tolerated the procedure with no reaction" in order to bill 36415, but if 3 months later the patient claims you had to stick her 15 times and developed some type of complication, it would be hard to dispute without any such documentation. I would lean toward the way you were documenting prior.
AAFP offers this guidance:

Venipuncture at a follow-up visit

What documentation is required when a medical assistant performs venipuncture on a date when the patient is not seen by the physician?
The documentation should refer to the written lab order by date and location (e.g., “in the 8/31/16 progress note”) and list the date of venipuncture, time, site, and patient tolerance of the procedure. All documentation should include the legible signature (written or electronic) and credentials of the individual performing the service.