How To Use CPT Code 36415

CPT 36415 describes the procedure of collecting a venous blood sample by inserting a needle into a vein. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 36415?

CPT 36415 is used to describe the procedure of collecting a blood sample from a vein. It involves the insertion of a needle into a vein, usually on the upper arm or elbow, to obtain the sample for diagnostic testing or other purposes.

2. Official Description

The official description of CPT code 36415 is: ‘Collection of venous blood by venipuncture.’

3. Procedure

1. The healthcare provider cleanses the venipuncture site with an antiseptic, typically 70% alcohol, and allows it to dry.
2. An elastic band is wrapped tightly around the upper arm to make the vein more visible and accessible.
3. The provider inserts a needle slowly into the vein, being careful not to puncture the posterior wall of the vein.
4. Approximately 5 mL of blood is drawn into a collection tube.
5. The needle is removed, and direct pressure is applied to the puncture site to stop any bleeding.

4. Qualifying circumstances

CPT 36415 is performed when a healthcare provider needs to collect a venous blood sample for diagnostic testing or other purposes. It is typically used for routine venipuncture or finger/heel/ear stick procedures. Modifier 63 should not be reported in conjunction with CPT 36415.

5. When to use CPT code 36415

CPT code 36415 should be used when a healthcare provider performs a venipuncture to collect a blood sample from a vein. It is appropriate for routine venipuncture procedures and should not be used for arterial punctures or other types of blood collection methods.

6. Documentation requirements

To support a claim for CPT 36415, the healthcare provider must document the following information:

• The reason for the venipuncture procedure
• The specific site of the venipuncture
• The date and time of the procedure
• The amount of blood collected
• Any complications or additional procedures performed
• The provider’s signature

7. Billing guidelines

When billing for CPT 36415, ensure that the procedure involves the collection of venous blood by venipuncture. It should not be reported with modifier 63. Consider the range of venipuncture and transfusion procedures (36400-36460) when selecting the appropriate code for billing.

8. Historical information

CPT 36415 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A phlebotomist collecting a blood sample from a patient’s vein for routine laboratory testing.
2. A nurse performing a venipuncture to obtain a blood sample for a patient’s annual physical examination.
3. A medical technologist collecting a blood sample from a patient for a specific diagnostic test.
4. A healthcare provider performing a venipuncture to obtain a blood sample for a research study.
5. A physician collecting a blood sample from a patient to monitor their medication levels.
6. A nurse practitioner performing a venipuncture to obtain a blood sample for a patient’s preoperative evaluation.
7. A laboratory technician collecting a blood sample from a patient for a blood transfusion.
8. A healthcare provider performing a venipuncture to obtain a blood sample for a patient’s genetic testing.
9. A phlebotomist collecting a blood sample from a patient’s vein for a drug screening.
10. A nurse performing a venipuncture to obtain a blood sample for a patient’s pregnancy test.