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36415 documentation

  1. #1
    Default 36415 documentation
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    Hello all,

    I'm looking for CMS, Noridian, trailblazer or any reputable source for venipuncture (36415) documentation requirements. Thanks so much

  2. #2
    Location
    Richmond, VA
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    I am looking for the same guidance, but for Palmetto MAC... but any guidance would be helpful as Palmetto doesn't have an LCDs/policies published for this.
    Have you found anything?
    Thanks!
    Annemarie Lincoln, CPC
    Richmond, VA

  3. #3
    Location
    Tacoma, WA
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    1,087
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    Quote Originally Posted by donnaber View Post
    Hello all,

    I'm looking for CMS, Noridian, trailblazer or any reputable source for venipuncture (36415) documentation requirements. Thanks so much
    I don't believe there are any specific documentation requirements for a simple blood draw. In many cases it is included in whatever other services are provided. CMS does not provide documentation requirements on this type of service.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  4. #4
    Location
    Richmond, VA
    Posts
    75
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    Thanks Arlene!

    What if that is the only service provide that day? We have patients coming in just for blood draws with the MA and nothing else? Shouldn't that be documented in some way?
    Annemarie Lincoln, CPC
    Richmond, VA

  5. #5
    Location
    Tacoma, WA
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    1,087
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    Quote Originally Posted by alincoln View Post
    Thanks Arlene!

    What if that is the only service provide that day? We have patients coming in just for blood draws with the MA and nothing else? Shouldn't that be documented in some way?
    Yes, they would document venipuncture and what site. Just standard documentation for doing a blood draw, similar to documenting an injection.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  6. #6
    Location
    Richmond, VA
    Posts
    75
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    Thanks Arlene!!!
    Annemarie Lincoln, CPC
    Richmond, VA

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