36415 Collection of venous blood by venipuncture – Fee schedule amount $3.10 – Private insurance pay upto $15

36416 Collection of capillary blood specimen (eg, finger, heel, ear stick) Fee schedule amount$3.1

P96l5 – Catheterization for collection of specimen(s)

General Definition

Venipuncture or phlebotomy is the puncture of a vein with a needle 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.”

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

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 venipunctureVenipunctureVenipuncture 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 procedure code most applicable to the method of blood withdrawal.

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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 professional provider claims submitted on a Form CMS-1500, whether performed in a provider’s office, a hospital laboratory, or an independent laboratory

When blood is drawn to be sent to a reference lab, use code 36415 for the venipuncture. HCPCS Code G0001 was deleted in 2005. The most appropriate current code for G0001 is 36415 and the current fee for this is $3.00.

• CPT 36415 will not be separately reimbursed when submitted with the following CPT codes:

• CPT 36416 will not be separately reimbursed when submitted with the following CPT codes:

Routine Venipuncture and the Collection of Blood Specimen from BCBS

A. Routine Venipuncture/Capillary Blood Collection Routine venipuncture CPT codes 36415 and 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.)

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.

Medicaid Update for CPT 36415

A specimen collection fee is limited only to venipuncture specimens drawn under the supervision of a physician to be sent outside of the office for processing. Any blood test obtained by heel or finger stick will post a mutually exclusive edit with 36415 – venipuncture. The following codes have been added as mutually exclusive to 36415: 82948–blood glucose, reagent strip, 85013–spun hematocrit, 85014–hematocrit, 85610–Prothrombin time, 83036– glycated hemoglobin, and 86318 –immunoassay for infectious agent by reagent strip when submitted with the modifier QW.


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CODING

Codes eligible for separate reimbursement when reported with a laboratory service: Code Description

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

36591 Collection of blood specimen from a completely implantable venous access device

36592 Collection of blood specimen using established central or peripheral venous catheterBilling and Coding Guidelines

A. Routine Venipuncture/Capillary Blood Collection

Routine venipuncture CPT codes 36415 and S9529 and capillary blood collection code 36416, are eligible for reimbursement when billed with an E/M and/or a laboratory service. Unless an additional routine venipuncture/capillary blood collection is clinically necessary, this service is only eligible for reimbursement once per member, per provider, per date of service.

CPT 36415 is only eligible to be billed once, even when multiple specimens are drawn or when multiple sites are accessed in order to obtain an adequate specimen size for the desired test(s). ODS 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.

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 eimbursement.

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 procedurecode.

Venipuncture is only eligible to be billed once, even when multiple specimens are drawn or when multiple sites are accessed in order to obtain adequate specimen size for the desired test(s).

PacificSource does not allow separate reimbursement for venipuncture when billed in conjunction with the blood or serum lab procedure performed on the same day and billed by the same provider will be denied as a subset to the lab test procedure

Modifier 90 (reference laboratory) will not bypass the subset edit. The outside laboratory that is actually performing the test will need to bill ODS directly in order for 36415 to be separately reimbursable to the provider performing the venipuncture to obtain the specimen for the outside laboratory.

The use of modifier 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. ODS 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)

UnitedHealthcare 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.

Codes 36415 and 36416 are only covered as Preventive when done for a preventive lab procedure that requires a blood draw.

FCHP will not reimburse separately for 36415 (collection of venous blood by venipuncture) and/or 36416 (collection of capillary blood specimen i.e., finger, heel, ear stick) when billed along with an E&M office visit (99201-05; 99211-15) or preventative medicine service (99381-87; 99391-97) or office-based lab CPT codes (i.e. CLIA waived tests).

• FCHP does reimburse 36415 when it is the sole service provided.

• FCHP does reimburse 36416 when it is the sole service provided.

The following procedures/services are included in reporting critical care when performed during the critical period and, therefore, should not be coded separately. Please see CPT for specific code definitions. 36000, 36410, 36415, 36540, 36600, 43752, 71010, 71015, 71020, 91105, 92953, 93561, 93562, 94002, 94003, 94004, 94660, 94662, 94760, 94761, 94762, 99090.

CPT code 36415 for Collection of venous blood by venipuncture is now payable byMedicare, but code 36416 Collection of capillary blood specimen (e.g., finger,heel, ear stick) remains as not payable by Medicare as a separate service.

From Anthem

Frequency/Maximum Occurrences per Code Group: Identifies when procedures within a code grouping are reported more than the once per date of service in any combination, our editing systems will allow one service within the grouping.

Example: Routine blood collection codes 36415, 36416, and S9529 are considered to be the same service; therefore, when all of these codes are reported on the same date of service by the same provider for the same patient, only one of the procedures will be allowed for that date of service.

Routine venipuncture CPT code 36415, and Healthcare Common Procedure Coding System (HCPCS Level II) 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.

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Frequency Editing and Laboratory and Venipuncture

Limit blood collection to 1 per date of service for any code in group 36415 (Collection of venous blood by venipuncture), 36416 (Collection of capillary blood specimen (finger, heel, ear stick)), and S9529 (Routine venipuncture for collection of specimen(s), single homebound, nursing home, or skilled nursing facility patient).