CPT Code and Definitions
36415 Collection of venous blood by venipuncture
36416 Collection of capillary blood specimen (e.g., finger, heel, ear stick)
G0471 Collection of venous blood by venipuncture or urine sample by catheterization from an individual in a SNF or by a laboratory on behalf of a HHA
S9529 Routine venipuncture for collection of specimen (s), single home bound, nursing home, or skilled nursing facility patient.
Venipuncture Definition
Venipuncture is the process of withdrawing a sample of blood for the purpose of analysis or testing. There are several different methods for the collection of a blood sample. The most common method and site of venipuncture is the insertion of a needle into the Cubital vein of the anterior forearm at the elbow fold.
Reimbursement Guidelines
A. For Professional and Clinical Laboratory Services (including Dialysis Centers and Home Health):
Venipuncture is the most common method used to obtain blood samples for blood or serum lab procedures. The work of obtaining the specimen sample is an essential part of performing the test.
Reimbursement for the venipuncture is included in the reimbursement for the lab test procedure code.
1. CPT Code 36415
a. For Moda Health Advantage:
36415 is eligible for separate reimbursement, consistent with Original Medicare payment policy.
b. For all other lines of business, the following policies apply:
i. CPT 36415 is only eligible to be billed once, even when multiple specimens are drawn or when multiple sites are accessed to obtain an adequate specimen size for the
desired test(s). (CMS4)
ii. Moda Health does not allow separate reimbursement for CPT 36415 (venipuncture) when billed in conjunction with a blood or serum lab procedure performed on the
same day and billed by the same provider (procedure codes in the 80048 - 89399 range). 36415 will be denied as a subset to the lab test procedure.
iii. If some of the blood and/or serum lab procedures are performed by the provider and others are sent to an outside lab, CPT 36415 is not eligible for separate reimbursement.
iv. Modifier 90 (reference laboratory) will not bypass the subset edit. The outside laboratory that is actually performing the test will need to bill Moda Health directly for the lab tests in order for 36415 to be separately reimbursable to the provider performing the venipuncture to obtain the specimen for the outside laboratory.
v. The use of modifiers XS, XP, XE, XU, or 59 with 36415 when blood/serum lab tests are also billed is not a valid use of the modifier. The venipuncture is not a separate procedure in this situation.
vi. Moda Health does allow separate reimbursement for CPT 36415 when the only other lab services billed for that date by that provider are for specimens not obtained by venipuncture (e.g. urinalysis).
* For Ambulatory Surgery Centers (ASC):
Per CMS policy, routine venipuncture or other routine collection of specimens, if needed, is not separately reimbursable to ASCs. These services are included in the packaged reimbursement for the primary procedure or service.
*For Outpatient Hospital (OPPS) Services:
The CMS OPPS Medically Unlikely Edit (MUE) limits apply for routine venipuncture procedure codes or other routine collection of specimens.
Coding Guidelines for CPT 36415
• When existing vascular access lines or selectively placed catheters are utilized to procure arterial or venous samples, reporting the sample collection separately is inappropriate. (CMS3)
• CPT codes 36500 or 75893 may occasionally be appropriate if more extensive work beyond routine venipuncture is required. For instance, if a physician needs to place a catheter to obtain a blood specimen from a specific organ or location. CPT codes 36500 (venous catheterization for selective organ blood sampling) or 75893 (venous sampling through catheter with or without angiography...) may be reported for venous blood sampling through a catheter placed for the sole purpose of venous blood sampling. CPT code 75893 includes concomitant venography if performed.(CMS3)
Background Information
Venipuncture or phlebotomy is the puncture of a vein with a needle or an IV catheter to withdraw blood. Venipuncture is the most common method used to obtain blood samples for blood or serum lab procedures, and is sometimes referred to as a “blood draw.” Collection of a capillary blood specimen (36416) or of venous blood from an existing access line or by venipuncture that does not require a physician’s skill or a cutdown is considered “routine venipuncture.”
Overview
This policy addresses the ConnectiCare, Inc. reimbursement policies pertaining to clinical laboratory and related laboratory services (e.g., venipuncture and the handling and conveyance of the specimen to the laboratory) for provider claims submitted on a CMS-1500, whether performed in a physician’s office, a hospital laboratory, or an independent laboratory. Note this policy does not address reimbursement for all laboratory codes. Coding relationships for laboratory topics not included within this policy are administered through ConnectiCare administrative and reimbursement policies. All services described in this policy may be subject to additional reimbursement policies.
If you are a physician, practitioner, or medical group, you may only bill for services that you or your staff perform. Pass-through billing is not permitted and may not be billed to our members. We only reimburse for laboratory services that you are certified to perform through the Federal Clinical Laboratory Improvement Amendments (CLIA). You must not bill our members for any laboratory services for which you lack the applicable CLIA certification. To validate whether a test requires CLIA visit CMS/FDA websites.
Policy statement:
Duplicate Laboratory Charges – Multiple Providers
Only one provider will be reimbursed when multiple providers bill identical services. ConnectiCare will reimburse the provider or entity that actually performed the test. Duplicate laboratory services are defined as identical or equivalent bundled laboratory codes. Note: For the purpose of this policy, CPT codes 82947 and 82948 are not considered to be equivalent codes:
• 82947 - Glucose; quantitative, blood (except reagent strip)
• 82948 - Glucose; blood, reagent strip
Pathologist and Physician Laboratory Providers
If a pathologist and another physician or other qualified health care professional’s offices submit identical laboratory codes for the same patient on the same date of service, only the pathologist’s service is reimbursable.
Place of Service
The Place of Service (POS) identifies where the laboratory service was performed. ConnectiCare uses the codes indicated in the Centers for Medicare and Medicaid Services (CMS) Place of Service Codes for Professional Claims Database to determine if laboratory services are reimbursable.
Examples:
• If the physician bills for lab services performed in his/her office, the POS code 11 for "Office" is reported.
• If an independent laboratory bills for a test on a sample drawn on an inpatient or outpatient of a hospital, the POS code 81 for "Independent Laboratory" is reported. Laboratory Panels
Individual laboratory codes, which together make up a laboratory panel code, will be combined into and reimbursed as the more comprehensive laboratory panel code as described under the specific laboratory panel headings below.
ConnectiCare also considers an individual component code included in the more comprehensive panel code when reported on the same date of service by the same individual physician or other qualified health care professional. The Professional Edition of the CPT book, Organ or DiseaseOriented Panel section states: "Do not report two or more panel codes that include any of the same constituent tests performed from the same patient collection. If a group of tests overlaps two or more panels, report the panel that incorporates the greater number of tests to fulfill the code definition and report the remaining tests using individual test codes."
In addition, it is not appropriate for a laboratory panel to be split amongst multiple laboratories or office/laboratory settings. This is also considered unbundling of a laboratory panel. Laboratory panels that have been split billed, or unbundled are not reimbursable. Venipuncture and Specimen Collection Specimen collection fees are not reimbursed when billed by the same provider who is rendering blood or related laboratory services Consistent with CMS, only one collection fee for each type of specimen per patient encounter, regardless of the number of specimens drawn, will be allowed. A collection fee will not be reimbursed to anyone who did not extract the specimen.
Venous blood collection by venipuncture and capillary blood specimen collection (CPT codes 36415 and 36416) will be reimbursed once per patient per date of service when reported by the Same Individual Physician or Other Qualified Health Care Professional. When CPT code 36416 is submitted with CPT code 36415, CPT code 36415 is the only venipuncture code considered eligible for reimbursement. No modifier overrides will exempt CPT code 36416 from bundling into CPT code 36415.
Consistent with CMS, ConnectiCare considers collection of a specimen from a completely implantable venous access device and from an established catheter (CPT codes 36591 and 36592) to be bundled into services assigned a CMS NPFS Status Indicator of A, R or T provided on the same date of service by the Same Individual Physician or Other Qualified Health Care Professional, for which payment is made. When CPT code 36591 is submitted with CPT code 36592, CPT code 36592 is the only venipuncture code considered eligible for reimbursement. No modifier overrides will exempt CPT code 36591 from bundling into CPT code 36592.
ConnectiCare considers venipuncture code S9529 (Routine venipuncture for collection of Specimen(s), single homebound, nursing home, or skilled nursing facility patient) a nonreimbursable service. The description for S9529 focuses on place of service for a service that is more precisely represented by CPT code 36415 and reported with the appropriate CMS place of service code.
Consistent with CMS, specimen collection HCPCS code G0471 is reimbursable only when a Specimen is collected from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency.
Laboratory Handling Laboratory handling and conveyance CPT codes 99000 and 99001 and HCPCS code H0048 are included in the overall management of a patient and are not separately reimbursed when submitted with another code, or when submitted as the only code on a claim for the same date of service.
Code Q0091
HCPCS code Q0091 (screening Papanicolaou smear, obtaining, preparing, and conveyance of cervical or vaginal smear to laboratory) is eligible for reimbursement for Medicare beneficiaries only. For all other products it is considered to be part of the E/M and Pap smear codes and is not eligible for separate reimbursement.
Guidelines for Billing Units When submitting multiple units of one code, the guidelines are based on code descriptions:
• If the CPT or HCPCS code description contains "per" or "each" or another unit of measurement and multiple services are provided, providers should bill the code on one line with the appropriate number of units.
• If the code does not contain a measurement such as "per" or "each" in the description of the code, providers should report one unit for all services.
Venipuncture and Specimen Collection
Consistent with CMS, only one collection fee for each type of Specimen per patient encounter, regardless of the number of Specimens drawn, will be allowed. A collection fee will not be reimbursed to anyone who did not extract the Specimen. Venous blood collection by venipuncture and capillary blood Specimen collection (CPT codes 36415 and 36416) will be reimbursed once per patient per date of service when reported by the Same Individual Physician or Other Qualified Health Care Professional. When CPT code 36416 is submitted with CPT code 36415, CPT code 36415 is the only venipuncture code considered eligible for reimbursement. No modifier overrides will exempt CPT code 36416 from bundling into CPT code 36415.
Consistent with CMS, UnitedHealthcare considers collection of a Specimen from a completely implantable venous access device and from an established catheter (CPT codes 36591 and 36592) to be bundled into services assigned a CMS NPFS Status Indicator of A, R or T provided on the same date of service by the Same Individual Physician or Other Qualified Health Care Professional, for which payment is made. When CPT code 36591 is submitted with CPT code 36592, CPT code 36592 is the only venipuncture code considered eligible for reimbursement. No modifier overrides will exempt CPT code 36591 from bundling into CPT code 36592.
UnitedHealthcare considers venipuncture code S9529 a non-reimbursable service. The description for S9529 focuses on place of service for a service that is more precisely represented by CPT code 36415 and reported with the appropriate CMS place of service code.
Consistent with CMS, specimen collection HCPCS code G0471 is reimbursable only when a Specimen is collected from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency.
Venipuncture is the process of withdrawing a sample of blood for the purpose of analysis or testing. There are several different methods for the collection of a blood sample. The most common method and site of venipuncture is the insertion of a needle into the cubital vein of the anterior forearm at the elbow fold. Please
refer to the coding section of this policy for the CPT code most applicable to the method of blood withdrawal.
This policy addresses the Health Plan’s reimbursement policies pertaining to clinical laboratory and related laboratory services (e.g., venipuncture and the handling and conveyance of the specimen to the laboratory) for provider claims submitted on a CMS-1500, whether performed in a physician’s office, a hospital laboratory,
or an independent laboratory.
. Routine Venipuncture and the Collection of Blood Specimen
A. Routine Venipuncture/Capillary Blood Collection
Healthcare Common Procedure Coding System (HCPCS Level II) code S9529 and capillary blood collection code 36416, are eligible for separate reimbursement when reported with an E/M and/or a laboratory service. Unless an additional routine venipuncture/capillary blood collection is clinically necessary, the frequency limit for any of these services is once per member, per provider, per date of service. The frequency limit will also apply to any combination of these codes reported on the same date of service for the same member by the same provider. (See also our Frequency Editing Reimbursement Policy.)
When routine venipuncture CPT code 36415 is reported with Evaluation and Management (E/M) office visit codes (99201-99205 and 99211-99215) then the routine venipuncture code is included in the reimbursement for office visit E/M services and not reimbursed separately.
Modifiers will not override the edit.
Routine venipuncture CPT 36415 is eligible for separate reimbursement when reported with a laboratory service.
In addition, HCPCS code G0471 for the collection of venous blood by venipuncture or urine sample by catheterization from an individual in a skilled nursing facility (SNF) or by a laboratory on behalf of a home health agency (HHA) collected by a laboratory technician that is employed by the laboratory that is performing the test will be eligible for separate reimbursement when reported with a laboratory service.
B. Collection of Blood Specimen from Access Device or Catheter
The Health Plan follows CPT coding guidelines which state that CPT codes 36591and 36592 should not be reported “…in conjunction with other services except a laboratory service.2 ” Therefore, CPT codes 36591 and 36592 are only eligible for separate reimbursement when reported with a laboratory service. See also our Bundled Services and Supplies Reimbursement Policy.
Coding
The following tables are provided as an informational tools only to help identify some of the procedures described above. The inclusion or exclusion of a specific code does not indicate eligibility for reimbursement under all circumstances.
According to Health Plan policy, the following codes are eligible for separate reimbursement when reported with a laboratory service:
Code Description
36415 Collection of venous blood by venipuncture
36420 Venipuncture, cutdown; younger than age 1 year
Coding Tips
Local anesthesia is included in these services. For handling or conveyance of a specimen transported to an outside laboratory, see 99000. For venipuncture on a patient younger than 3 years of age, see 36400–36406. For venipuncture requiring physician skill on a patient 3 years of age or older, see code 36410. Do not report code 36420 if providedwith critical care; see codes 99468–99480. Code 36425 should not be reportedwith endovenous ablation(36475–36479)
Terms To Know
critical care. Treatment of critically ill patients in a variety of medical emergencies that requires the constant attendance of the physician (e.g., cardiac arrest, shock, bleeding, respiratory failure, postoperative complications, critically ill neonate). cutdown. Small, incised opening in the skin to expose a blood vessel, especially over a vein (venous cutdown) to allow venipuncture and permit a needle or cannula to be inserted for the withdrawal of blood or administration of fluids.
venipuncture. Piercing a vein through the skin by a needle and syringe or sharp-ended cannula or catheter to draw blood, start an intravenous infusion, instill medication, or inject another substance such as radiopaque dye
Venipuncture is the process of collecting or “drawing” blood from a vein and the most common way to collect blood specimens for laboratory testing. It is the most frequent procedure performed by a phlebotomist and the most important step in this procedure is patient identification. This chapter addresses how to correctly identify all types of patients and how to safely obtain high-quality blood specimens from them. Venipuncture techniques covered in this chapter include ETS, butterfly, and syringe procedures on arm and hand veins. This chapter also addresses challenges and unique issues associated with pediatric, geriatric, dialysis, long-term care, home care, and hospice patients. Venipuncture procedures in this chapter conform to CLSI standards.
Cognitively Impaired or Combative Patients Some patients may display unpredictable or sudden movements and behaviors that could pose a danger to themselves, the phlebotomist or others nearby. If a patient exhibits such behaviors it is essential for an additional person or employee to be enlisted to assist if necessary. In addition, make certain you have an obstructed exit route in case it is needed. Also be mindful of where you place equipment, being certain to keep it out of the reach of the patient. As with venipuncture on every patient, always have a gauze pad ready and be prepared to release the tourniquet quickly in case the patient pulls the needle out, or suddenly jerks causing the needle to either come out or go deep into the arm. Should the needle penetrate deep into the arm the patient’s nurse or healthcare provider must be informed and the incident documented according to facility policy.
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