How to properly document and bill for venipuncture

What is the correct way to code for venipuncture? Does the billing change if the procedure is performed by a medical assistant (MA) instead of a physician?

If your physician has seen the patient prior to the MA performing the venipuncture (on the same day or a previous date) and instructs the MA to perform the venipuncture, the billing is the same regardless of whether the physician or MA actually performs the service, based on incident-to guidelines. Just make sure that the physician’s order and the performance of the venipuncture are documented.

Here are some coding tips:

1. Select the right code. Venipuncture coding is described using CPT 36415 (collection of venous blood by venipuncture).

2. Don’t append modifier -63. Modifier -63 describes a procedure performed on an infant less than 4 kg. CPT instructs us that use of modifier -63 with 36415 is inappropriate.

3. Report a single unit of 36415, per episode of care, regardless of how many times venipuncture is performed. This instruction comes from the 2018 National Correct Coding Initiative (NCCI) Policy Manual, Chapter V: Respiratory, Cardiovascular, Hemic and Lymphatic Systems CPT Codes 30000-39999. The Policy Manual stipulates:

CPT code 36415 describes collection of venous blood by venipuncture. Each unit of service (UOS) of this code includes all collections of venous blood by venipuncture during a single episode of care regardless of the number of times venipuncture is performed to collect venous blood specimens. Two or more collections of venous blood by venipuncture during the same episode of care are not reportable as additional UOS [Units of Service].

Per the Policy Manual, “An episode of care begins when a patient arrives at a facility for treatment and terminates when the patient leaves the facility.”

Medicare will not reimburse for routine venipuncture, and neither will many private payers.

CPT includes codes to report venipuncture requiring a physician’s skill, which are chosen according to the patient’s age and, for those patients younger than 3 years old, by the vein accessed:

• 36400  Venipuncture, younger than age 3 years, necessitating physician skill, not to be used for routine venipuncture; femoral or jugular vein
• 36405 scalp vein
• 36406 other vein
• 36410  Venipuncture, age 3 years or older, necessitating physician skill (separate procedure), for diagnostic or therapeutic purposes (not to be used for routine venipuncture)

Medicare will separately reimburse for 36400-36410, but only if documentation supports medical necessity. Documentation should describe the circumstances requiring physician skill.