How To Use CPT Code 36425

CPT 36425 describes the procedure of venipuncture, specifically for patients aged one year or older. This article will cover the official description, the step-by-step procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 36425?

CPT 36425 is used to describe the venipuncture procedure performed on patients who are one year of age or older. This code is specifically for accessing a vein to collect a blood sample or administer medication through injection.

2. Official Description

The official description of CPT code 36425 is: ‘Venipuncture, cutdown; age 1 or over.’

3. Procedure

1. The healthcare provider begins by cleaning the venipuncture site, typically on the upper arm or elbow, with an appropriate antiseptic.
2. After allowing the area to dry, the provider makes an incision directly over the vein.
3. Next, a needle is slowly inserted into the vein, ensuring not to puncture the posterior wall of the vein.
4. About 5 mL of blood is collected into a collection tube or medication is introduced.
5. Finally, the needle is removed, and pressure is applied to the puncture site to stop any bleeding.

4. Qualifying circumstances

CPT 36425 is applicable for patients aged one year or older who require venipuncture for blood sample collection or medication administration. It is important to note that this code should not be reported in conjunction with codes 36475, 36476, or 36478.

5. When to use CPT code 36425

CPT code 36425 should be used when performing venipuncture on patients who are one year of age or older. It is important to ensure that the procedure is specifically for accessing a vein and collecting a blood sample or administering medication through injection.

6. Documentation requirements

To support a claim for CPT 36425, the healthcare provider must document the following information:

• Patient’s age, confirming they are one year or older
• Specific site of venipuncture
• Amount of blood collected or medication administered
• Any complications or additional procedures performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 36425, ensure that the procedure is performed on a patient who is one year of age or older. It is important to note that this code should not be reported with codes 36475, 36476, or 36478. Additionally, it is essential to consider the location of the testing when coding venipuncture and transfusion procedures.

8. Historical information

CPT 36425 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 healthcare provider performing venipuncture on a 5-year-old patient to collect a blood sample for laboratory testing.
2. A nurse administering medication through injection via venipuncture on a 30-year-old patient.
3. A phlebotomist collecting a blood sample from the vein of a 70-year-old patient for diagnostic purposes.
4. A medical technologist performing venipuncture on a 45-year-old patient to obtain blood for a transfusion.
5. A physician conducting venipuncture on a 60-year-old patient to administer intravenous medication.
6. A healthcare provider performing venipuncture on a 25-year-old patient to collect blood for a research study.
7. A nurse drawing blood from the vein of a 55-year-old patient for a routine health check-up.
8. A medical assistant performing venipuncture on a 35-year-old patient to administer intravenous fluids.
9. A phlebotomist collecting a blood sample from the vein of a 50-year-old patient for genetic testing.
10. A healthcare provider performing venipuncture on a 65-year-old patient to administer a contrast agent for imaging purposes.