Novitas Solutions developed this article to help you understand the correct way to submit venipuncture claims.
Current Procedural Terminology (CPT) code 36415 does not necessitate a physician’s skill. Routine venipuncture for specimen collection may be safely and effectively performed by a properly trained and licensed non-physician professional (e.g., nurse, phlebotomist, and medical technician) on peripheral superficial veins of the upper or lower extremities.
CPT code 36410, venipuncture necessitating physician's skill, is defined as a venipuncture for which the skill of a physician is required for diagnostic or therapeutic purposes.
Note: 36410 should not to be used for routine venipuncture.
Only one collection fee is allowed for each type of specimen for each patient encounter, regardless of the number of specimens drawn.
Payment for CPT 36410 is reimbursable when it is necessary for the venipuncture to actually be performed by a physician; specifically, when it is medically necessary and reasonable to perform the venipuncture.
The medical record must contain:
Justification that the venipuncture required the skill of a physician and therefore it was reasonable and necessary for venipuncture to be performed by a physician (e.g., MD or DO) or qualified non-physician practitioner (e.g., Nurse Practitioner, Physician's Assistant).
The clinical condition(s) that necessitated a physician (e.g., MD or DO) or qualified non-physician practitioner (e.g., Nurse Practitioner, Physician's Assistant) perform the venipuncture.
Demonstrate that the physician (e.g., MD or DO) or qualified non-physician practitioner (e.g., Nurse Practitioner, Physician's Assistant) performed venipuncture.
The clinical reason(s) for the venipuncture must be documented in the medical record.
If any of the above information is not included in the documentation, it may result in the denial of the claim.
Centers for Medicare & Medicaid Internet Only Manual, Publication 100-04, Claims Processing Manual, Chapter 16, Section 60