Venipuncture documentation requirements

Post here your questions regarding auditing ,coding, documentation, and compliance. Also, join in on the conversation- help your fellow auditors and compliance professionals in the industry.

Moderators: Shannon DeConda, NAMAS Moderator

Venipuncture documentation requirements

Postby aderaad » Fri Aug 25, 2017 7:40 pm

I need guidance regarding the documentation requirements for venipuncture, CPT 36415. We have a clinic that has patients come in for the sole purpose of a blood draw. The blood is then sent to an outside laboratory to have the tests performed. Can you tell me what type of documentation is required from the staff member who does this blood draw in order to support coding 36415?

We are thinking the documentation should include the site the blood was drawn from, the number of tubes collected and how the patient tolerated the procedure redness/no redness at site, etc. Unfortunately, we are unable to find this clearly outlined in black and white anywhere.
Posts: 3
Joined: Fri May 05, 2017 4:41 pm

Re: Venipuncture documentation requirements

Postby bill.wong » Tue Aug 29, 2017 5:41 pm

Yes. If you can get that out of your nursing staff, that is a blessing. At one of my previously employment, we were lucky to get "Labs drawn" which was suffice for us. Ideally, like any other procedure or service, I would like to see as much as the following as I can (some may not apply):

• Procedure
• Indication/Diagnosis
• Consent
• Description of Procedure
• Findings/Assessment
• Complications
• Signature
AHIMA Approved ICD-10-CM/PCS Trainer
Sr. Coding & Compliance Educator/Auditor
Posts: 31
Joined: Wed Aug 17, 2016 10:02 pm

Return to Medical Auditing Forum

Who is online

Users browsing this forum: No registered users and 1 guest